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OBJECTIVE: This study aims to report the long-term outcomes after percutaneous coronary intervention (PCI) in human immunodeficiency virus (HIV+) patients. BACKGROUND: Sparse data exists regarding the risk of patients with HIV who undergo PCI. METHODS: Using a case-control design, we compared baseline characteristics, procedure-related outcomes, in-hospital, and 2-year clinical outcomes of 112 consecutive HIV+ patients versus 112 HIV- controls matched for age, gender, and diabetes mellitus who underwent PCI from April 2003 to September 2011. RESULTS: Baseline characteristics were generally comparable, save for more African Americans and history of chronic renal insufficiency in the HIV+ vs. HIV- group (62.5% vs. 21.4%, P < 0.001) and (27.7% vs. 9.9%, P < 0.001). There was no correlation between CD4 nadir count and extent and diffuseness of coronary artery disease. The occurrence of major adverse cardiac events at 2 years was similar in both groups. Multivariable analysis for independent correlates of major adverse cardiac events at 2 years detected patients with a history of chronic renal insufficiency (OR: 2.44, 95% confidence interval: 1.02-5.83; P = 0.04) and acute myocardial infarction (OR: 2.92, 95% confidence interval: 1.39-6.15; P = 0.005) as correlates for outcome. Post-hoc analysis showed that drug-eluting stent (DES) use in the HIV+ group was beneficial. CONCLUSION: PCI in HIV+ patients is safe, with high procedural success rates, and produces similar outcomes to those seen in HIV- patients at 2 years. HIV+ patients should be treated with DES if possible.
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Enfermedad de la Arteria Coronaria/terapia , Infecciones por VIH/complicaciones , Intervención Coronaria Percutánea , Anciano , Distribución de Chi-Cuadrado , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Bases de Datos Factuales , Stents Liberadores de Fármacos , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/mortalidad , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/etiología , Oportunidad Relativa , Selección de Paciente , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/mortalidad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIMS: This study aimed to evaluate incidence and correlates for low platelet count after transcatheter aortic valve replacement (TAVR) and to determine a possible association between acquired thrombocytopenia and clinical outcomes. METHODS AND RESULTS: Patients undergoing TAVR from two medical centres were included in the study. They were stratified according to nadir platelet count post procedure: no/mild thrombocytopenia, ≥100 × 10(9)/L; moderate, 50-99 × 10(9)/L; and severe, <50 × 10(9)/L. A total of 488 patients composed of the study population (age 84.7 ± 7.5 years). At a median time of 2 days after TAVR, 176 patients (36.1%) developed significant thrombocytopenia: 149 (30.5%) moderate; 27 patients (5.5%) severe. Upon discharge, the vast majority of patients (90.2%) had no/mild thrombocytopenia. Nadir platelet count <50 × 10(9)/L was highly specific (96.3%), and a count <150 × 10(9)/L highly sensitive (91.2%), for predicting 30-day death (C-statistic 0.76). Patients with severe acquired thrombocytopenia had a significantly higher mortality rate at 1 year (66.7% for severe vs. 16.0% for no/mild vs. 20.1% for moderate; P < 0.001). In multivariate logistic regression, severe thrombocytopenia was independently associated with 1-year mortality (hazard ratio 3.44, CI: 1.02-11.6; P = 0.046). CONCLUSIONS: Acquired thrombocytopenia was common after TAVR and was mostly resolved at patient discharge. The severity of thrombocytopenia after TAVR could be used as an excellent, easily obtainable, marker for worse short- and long-term outcomes after the procedure.
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Estenosis de la Válvula Aórtica/cirugía , Trombocitopenia/etiología , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano de 80 o más Años , Femenino , Humanos , Tiempo de Internación , Masculino , Recuento de Plaquetas , Resultado del TratamientoRESUMEN
Implantation of coronary stents should be performed with high precision to ensure optimal clinical results. In some clinical conditions, during the cardiac cycle, significant movement of the predeployed stent may impact its implantation accuracy. We describe a case in which a patient had a short ostial left anterior descending artery stenosis and hyperkinetic left ventricle, resulting in significant movement of the stent inside the vessel lumen during the cardiac cycle. Intracoronary adenosine was used to create temporary heart block to enable accurate stent implantation.
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Adenosina/administración & dosificación , Estenosis Coronaria/terapia , Bloqueo Cardíaco , Intervención Coronaria Percutánea/instrumentación , Stents , Función Ventricular Izquierda/efectos de los fármacos , Adulto , Angiografía Coronaria , Estenosis Coronaria/diagnóstico , Estenosis Coronaria/fisiopatología , Electrocardiografía , Femenino , Humanos , Inyecciones , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
OBJECTIVE: To evaluate the axial integrity of different coronary stents using intravascular ultrasound (IVUS). BACKGROUND: Longitudinal stent deformation was recently reported. METHODS: Consecutive patients who underwent IVUS analysis after drug-eluting stent (DES) implantation for de novo coronary lesions were evaluated. Stent length was compared with label length for calculation of absolute change and relative difference (absolute change divided by label length). RESULTS: A total of 233 DES utilizing five different platforms were included. The median absolute change in stent length was 0.90 mm (interquartile range [IQR] 0.48-1.39) and the relative difference was 5.24% (IQR 2.55-8.29). There was no significant difference among the groups in median absolute or relative change: Cypher 0.89 mm/3.89%, Taxus 0.88 mm/5.39%, Endeavor 1.16 mm/6.77%, Xience V 0.86 mm/5.80%, and PROMUS Element 0.79 mm/5.34% (P = 0.085, P = 0.072, respectively). Multivariate logistic regression revealed that the Cypher stent was independently correlated with a lower change in length, whereas stent label length and deployment pressure were correlated with higher absolute change. CONCLUSION: The axial integrity of DES platforms examined in vivo was high, with only mild changes in stent length after implantation. While there are differences between first- and second-generation DES, axial integrity among second-generation DES was similar.
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Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/diagnóstico por imagen , Intervención Coronaria Percutánea/métodos , Stents , Ultrasonografía Intervencional/métodos , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Falla de PrótesisRESUMEN
OBJECTIVE: We aimed to identify the correlates in the development of post-percutaneous coronary intervention (PCI) iatrogenic femoral pseudoaneurysm (IFP). BACKGROUND: IFP is one of the more common vascular complications of PCI. METHODS: From February 2008 to June 2012, 10,169 consecutive patients who underwent PCI were retrospectively studied. Patients who developed postprocedural IFP were identified at a single, large tertiary PCI center. RESULTS: One hundred thirty-nine patients developed IFP (1.38%) and were compared to the cohort that did not. Baseline characteristics were comparable, although patients in the IFP group were older and had a higher incidence of insulin-requiring diabetes mellitus and chronic renal insufficiency (68.4 ± 12.9 vs. 65.4 ± 12.3 years, P = 0.004; 23.9% vs. 14.6%, P = 0.002; and 26.6% vs. 17.3%, P = 0.004, respectively). The non-IFP group had more men and a higher use of vascular closure devices, respectively (64.7% vs. 49.6%, P < 0.001; and 54.1% vs. 26.5%, P < 0.001). There was no significant difference in the use of dual antiplatelet or anticoagulation therapies between the 2 cohorts. Univariable correlates for the development of IFP were female gender, insulin-requiring diabetes mellitus, chronic renal insufficiency, and use of manual compression to achieve hemostasis. On multivariable analysis, the successful deployment of vascular closure device for hemostasis reduced the occurrence of IFP (odds ratio 0.31, 95% confidence interval 0.21-0.46, P < 0.0001). CONCLUSION: The development of IFP following PCI is not uncommon and the appropriate use of vascular closure devices to achieve hemostasis should be encouraged to minimize this vascular complication.
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Aneurisma Falso/etiología , Arteria Femoral , Enfermedad Iatrogénica , Intervención Coronaria Percutánea , Anciano , Aneurisma Falso/epidemiología , Diabetes Mellitus Tipo 1/complicaciones , Femenino , Hemostasis , Humanos , Enfermedad Iatrogénica/epidemiología , Masculino , Intervención Coronaria Percutánea/métodos , Complicaciones Posoperatorias , Insuficiencia Renal Crónica/complicacionesRESUMEN
Transcatheter aortic valve replacement (TAVR) provides an option for extreme-risk patients who underwent reoperation for a failed surgical aortic bioprosthesis. Long-term data on patients who underwent TAVR within a failed surgical aortic valve (TAV-in-SAV) are limited. The CoreValve Expanded Use Study evaluated patients at extreme surgical risk who underwent TAV-in-SAV. Outcomes at 5 years were analyzed by SAV failure mode (stenosis, regurgitation, or combined). Echocardiographic outcomes are site-reported. TAV-in-SAV was attempted in 226 patients with a mean age of 76.7 ± 10.8 years; 63.3% were male, the Society of Thoracic Surgeons predicted risk of mortality score was 9.0 ± 6.7%, and 87.5% had a New York Heart Association classification III or IV symptoms. Most of the failed surgical bioprostheses were stented (81.9%), with an average implant duration of 10.2 ± 4.3 years. The 5-year all-cause mortality or major stroke rate was 47.2% in all patients; 54.4% in the stenosis, 37.6% in the regurgitation, and 38.0% in the combined groups (p = 0.046). At 5 years, all-cause mortality was higher in patients with versus without 30-day severe prosthesis-patient mismatch (51.7% vs 38.3%, p = 0.026). The overall aortic valve reintervention rate was 5.9%; highest in the regurgitation group (12.6%). The mean aortic valve gradient was 14.1 ± 9.8 mm Hg and effective orifice area was 1.57 ± 0.70 at 5 years. Few patients had >mild paravalvular regurgitation at 5 years (5.5% moderate, 0.0% severe). TAV-in-SAV with supra-annular, self-expanding TAVR continues to represent a safe and lasting intermediate option for extreme-risk patients who have appropriate sizing of the preexisting failed surgical valve. Clinical and hemodynamic outcomes were stable through 5 years.
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Estenosis de la Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Masculino , Anciano , Anciano de 80 o más Años , Femenino , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estudios de Seguimiento , Constricción Patológica/etiología , Constricción Patológica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/etiología , Resultado del Tratamiento , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Instrumentos Quirúrgicos , Diseño de Prótesis , Factores de RiesgoRESUMEN
BACKGROUND: Red cell distribution width (RDW), a measure of variability in the size of circulating erythrocytes, is an independent predictor of mortality in cardiovascular disease and in patients undergoing percutaneous coronary intervention (PCI). We set out to determine if RDW is a prognostic marker of major bleeding post-PCI. METHODS: The study population included 6,689 patients who were subjected to PCI. The RDW was derived from a complete blood count drawn before PCI. Major inhospital bleeding was defined as a hematocrit decrease ≥12%, hemoglobin drop of ≥4, transfusion of ≥2 units of packed red blood cells, retroperitoneal, or gastrointestinal or intracranial bleeding. Multivariable logistic analysis of major inhospital bleeding was performed using a logistic regression model that comprised the National Cardiovascular Data Registry (NCDR) risk score model as a single variable. RESULTS: Major bleeding (P < .001), vascular complications (P = .005), and transfusions (P < .001) were significantly higher in patients with higher baseline RDW values. After adjustment for known bleeding correlates, RDW was a significant predictor for major bleeding (odds ratio 1.12, 95% CI 1.06-1.19, P < .001). Although the c statistic of the NCDR risk prediction model changed from 0.730 to 0.737 (P = .032), the net reclassification improvement increased significantly after the addition of RDW as a continuous variable (17.3% CI 6.7%-28%, P = .002). CONCLUSIONS: Red cell distribution width, an easily obtainable marker, has an independent, linear relationship with major bleeding post-PCI and incrementally improves the well-validated NCDR risk prediction model. These data suggest that further investigation is necessary to determine the relationship of RDW and post-PCI bleeding.
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Enfermedad de la Arteria Coronaria/cirugía , Eritrocitos , Intervención Coronaria Percutánea , Cuidados Posoperatorios/métodos , Hemorragia Posoperatoria/sangre , Anciano , Enfermedad de la Arteria Coronaria/sangre , Recuento de Eritrocitos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/diagnóstico , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , StentsRESUMEN
Distal anastomotic lesions are the most common reason for venous and arterial graft failure. Redo coronary artery bypass surgery carries a higher risk for mortality and non-fatal myocardial infarction. Many operators therefore consider percutaneous coronary intervention as a good alternative for relieving angina symptoms in this subset of patients with anastomotic lesions. However, the best percutaneous method for treating these lesions is still controversial. Here we review reported data on the incidence, pathogenesis, and treatment of distal anastomotic lesions in both venous and arterial bypass grafts.
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Angina de Pecho/terapia , Angioplastia Coronaria con Balón , Puente de Arteria Coronaria/efectos adversos , Oclusión de Injerto Vascular/terapia , Angina de Pecho/diagnóstico , Angina de Pecho/epidemiología , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/instrumentación , Angiografía Coronaria , Oclusión de Injerto Vascular/diagnóstico , Oclusión de Injerto Vascular/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Stents , Resultado del TratamientoRESUMEN
This is a classic case of intramural hematoma causing acute myocardial infarction soon after successful stenting. This case illustrates the importance of intravascular ultrasound imaging to diagnose the underlying cause of coronary occlusion after successful stenting to guide the optimal treatment in such cases.
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Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/etiología , Estenosis Coronaria/terapia , Stents Liberadores de Fármacos , Hematoma/etiología , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/terapia , Estenosis Coronaria/diagnóstico , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/etiología , Diagnóstico Diferencial , Femenino , Hematoma/diagnóstico , Hematoma/terapia , Humanos , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/terapia , Valor Predictivo de las Pruebas , Factores de Riesgo , Ultrasonografía IntervencionalRESUMEN
OBJECTIVE: To determine the best revascularization strategy when treating distal anastomotic lesions. BACKGROUND: Distal anastomotic lesions are the most common reason for venous graft failure especially early after bypass surgery. However, the best percutaneous method for treating these lesions is still controversial. METHODS: All patients from 2/2000 to 1/2011 who underwent percutaneous coronary intervention of bypass graft distal anastomotic lesions were retrospectively enrolled. Among the 139 patients included, 26 (18.7%) were treated with plain old balloon angioplasty (POBA), 68 (48.9%) with bare metal stents (BMS), and 45 (32.4%) with drug-eluting stents (DES). RESULTS: Baseline characteristics were generally comparable among the 3 groups. At 6 months' follow-up, the highest rate of target lesion revascularization-major adverse cardiac events (TLR-MACE) was seen in the BMS group compared to the DES and POBA groups (16.2 vs. 2.2 vs. 3.8%, respectively, P=0.03), which was driven mainly by the highest rates of death and TLR in the BMS group (11.8 and 4.7%, respectively). At 1-year follow-up, a higher rate of TLR-MACE was seen in the BMS group compared to the DES and POBA groups (20.6 vs. 11.1 vs. 7.7%, respectively, P=0.19). After adjustment, on Cox regression analysis for hazard ratios, no significant differences were found among the 3 groups at 1-year follow-up of TLR-MACE. CONCLUSIONS: When selecting the treatment modality for saphenous vein graft distal anastomotic lesions, BMS implantation should be discouraged while POBA and DES implantation can be performed with favorable long-term outcomes. The optimal treatment approach should be evaluated in large, randomized clinical trials.
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Puente de Arteria Coronaria/efectos adversos , Reestenosis Coronaria/terapia , Oclusión de Injerto Vascular/terapia , Intervención Coronaria Percutánea , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón , Puente de Arteria Coronaria/métodos , Stents Liberadores de Fármacos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Vena Safena/trasplante , Stents , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: This study aimed to compare the safety and efficacy of everolimus-eluting stents (EES) to first-generation drug-eluting stents (DES) in multivessel disease (MVD). BACKGROUND: Second-generation EES have demonstrated superiority over first-generation DES for single-vessel disease, although the merits of EES in MVD are less established. METHODS: A cohort of 1,285 patients (3,124 lesions) with ≥ 2 diseased vessels were treated with either first-generation DES (n = 1,002) or EES (n = 283). The rates of death, myocardial infarction, target lesion revascularization, target vessel revascularization, definite stent thrombosis, and major adverse cardiac events (MACE), defined as the combined incidence of target vessel revascularization, death, and non-fatal myocardial infarction, were compared at 1 year. RESULTS: Baseline characteristics were similar except for a lower left ventricular ejection fraction and a lower incidence of stable angina pectoris in the first-generation DES group (P = 0.001 and 0.013, respectively). At 1 year, the MACE rate was lower in the EES group (9.5P% vs. 15.7%; P = 0.01). Multivariable analysis demonstrated that EES use predicted a higher chance of freedom from MACE at 1 year (hazard ratio 0.58 [0.38-0.87]; P = 0.009; 95% confidence interval). CONCLUSIONS: The use of EES in patients with MVD is safe with signals for improved effectiveness compared to first-generation DES. Randomized trials comparing new-generation DES to coronary artery bypass grafting surgery are warranted.
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Enfermedad Coronaria/terapia , Stents Liberadores de Fármacos , Sirolimus/análogos & derivados , Anciano , Angiografía Coronaria , Enfermedad Coronaria/complicaciones , Everolimus , Femenino , Humanos , Masculino , Sirolimus/administración & dosificación , Resultado del TratamientoRESUMEN
Calcified aortic stenosis has become the most common form of acquired valvular heart disease in very old patients. Despite this fact, a majority of these patients were turned down by surgery owing to a risk of mortality > 10% in patients older than 90 years. In recent years, transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option for severe aortic stenosis. However, there is a paucity of data regarding the outcomes of TAVI in patients older than 100 years. We present the oldest patient who has undergone successful TAVI reported in the current literature.
RESUMEN
OBJECTIVE: This study aimed to assess the long-term safety and clinical effectiveness of the Xience V everolimus-eluting stent (EES) compared to both Taxus paclitaxel-eluting stent (PES) and Cypher sirolimus-eluting stent (SES) in an unselected patient population. BACKGROUND: There are limited long-term data comparing Xience V EES vs the first-generation Cypher SES. METHODS: This retrospective analysis included 6069 patients treated with Cypher SES, Taxus PES, or Xience V EES from 2003-2009 at our institution. Patients were followed by telephone contact or office visit up to 2 years after the index procedure. RESULTS: Baseline characteristics were generally comparable, with the exception of a significantly higher prevalence of diabetes mellitus, systemic hypertension, history of angioplasty, and coronary bypass surgery among Xience V EES patients. At 2 years, the incidence of major adverse cardiovascular events was 13.3% (Xience V EES) vs 17.8% (Cypher SES) vs 22% (Taxus PES) (P<.001). The main drivers for the differences in event rates were lower mortality, the need for target vessel revascularization, and Q-wave myocardial infarction. Stent thrombosis was lowest in Xience V EES patients (0.2% vs 1.2% SES vs 0.7% PES, respectively; P=.01). A landmark analysis after 1 year showed that the benefits of Xience V EES continued in long-term follow-up. CONCLUSIONS: In a contemporary clinical United States practice with an unselected patient population, Xience V EES use was associated with improved safety profile and reduction of all-cause mortality and stent thrombosis when compared to both first-generation drug-eluting stents. This superiority continues to widen from 1 to 2 years.
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Enfermedad de la Arteria Coronaria/terapia , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/métodos , Complicaciones Posoperatorias/epidemiología , Sirolimus/análogos & derivados , Anciano , Estenosis Coronaria/epidemiología , Estenosis Coronaria/etiología , Stents Liberadores de Fármacos/efectos adversos , Everolimus , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Paclitaxel , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: Our study aimed to assess the characteristics and outcomes of transfemoral approach (TFA) versus the initial steps of a transradial approach (TRA) program and to assess the learning curve of TRA in contemporary, US practice. BACKGROUND: When compared to TFA, TRA has been shown to lower bleeding and vascular complications during percutaneous coronary intervention (PCI). However, use of TRA is still low. There are limited data regarding the characteristics of TRA learning curve, especially in an era with designated TRA equipment. METHODS: Consecutive patients undergoing PCI in a single US center were divided into two cohorts according to vascular access approach: the last 250 TFA patients prior to the establishment of a TRA program and the initial 239 TRA patients following the establishment of a TRA program. Subgroup analysis of the TRA group, which was divided into five sequential case groups of 50 cases per group, was performed in order to assess TRA learning curve. RESULTS: Overall, the baseline characteristics of TFA vs. TRA groups were comparable. Fluoroscopy time was significantly longer during TRA procedures (18±11 vs. 15±8min, respectively, p=0.002); however, contrast use was lower during TRA procedures (161±72 vs. 180±63ml, respectively, p=0.002). In-hospital outcomes were similar between the two groups, with low frequencies of mortality, myocardial infarction, and stent thrombosis. Subanalysis of TRA group for learning curve assessment showed no major differences in patient demographics among the five subgroups. In the initial cases, more PCI was performed among non-acute cases (62% in patients 1-50 vs. 8-27% in patients 51-239, p<0.001). Despite these differences, characteristics of the treated vessels were similar between groups. There was no significant change in fluoroscopy time or in the amount of iodinated contrast volume delivered. Similarly, no differences in procedural, in-hospital, and long-term outcomes were documented. CONCLUSIONS: Adopting TRA as a default is feasible for high-volume operators without significant learning curve effects.
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Cateterismo Cardíaco/métodos , Cateterismo Periférico/métodos , Competencia Clínica , Enfermedad de la Arteria Coronaria/terapia , Arteria Femoral , Curva de Aprendizaje , Intervención Coronaria Percutánea/métodos , Arteria Radial , Anciano , Cateterismo Cardíaco/efectos adversos , Cateterismo Periférico/efectos adversos , Medios de Contraste , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Trombosis Coronaria/etiología , Trombosis Coronaria/mortalidad , District of Columbia , Estudios de Factibilidad , Femenino , Hospitales de Alto Volumen , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Desarrollo de Programa , Radiografía Intervencional , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
Drug-eluting stents have shown promising clinical results in the treatment of coronary artery disease, including in women. Studies with first-generation drug-eluting stents, however, have reported higher rates of stent thrombosis (ST). The aim of this study was to evaluate the safety and efficacy of second-generation everolimus-eluting stents (EES) versus first-generation sirolimus-eluting stents (SES) in women. The study included 1,649 women; 1,152 (70%) received SES and 497 (30%) received EES. In-hospital and 1-, 6-, and 12-month clinical outcomes were analyzed and compared. Correlates of major adverse cardiac events and ST were identified. Baseline clinical characteristics were similar between stent types, although more peripheral vascular disease and family history of coronary artery disease were seen in the SES group, while more unstable angina pectoris at initial diagnosis was more prevalent in the EES group. The EES group had more type C and distal lesions. There was a higher rate of target vessel revascularization and major adverse cardiac events in the SES group (14.7% vs 10.8%, p = 0.04) at 1 year. ST tended to be higher in the SES group (1.5% vs 0.4%, p = 0.06) at 6 and 12 months. After adjustment, multivariate analysis indicated that the EES group was less likely to have target vessel revascularization and major adverse cardiac events (hazard ratio 0.67, 95% confidence interval 0.47 to 0.95, p = 0.024) and had lower rates of ST (hazard ratio 0.09, 95% confidence interval 0.01 to 0.70, p = 0.022) at 1 year. In conclusion, contemporary use of EES in women is associated with improvement in efficacy and safety profiles compared to SES; however, a large randomized trial is needed to confirm this conclusion.
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Enfermedad de la Arteria Coronaria/terapia , Trombosis Coronaria/prevención & control , Sirolimus/análogos & derivados , Sirolimus/farmacología , Anciano , Angioplastia Coronaria con Balón , Antineoplásicos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/mortalidad , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/mortalidad , Stents Liberadores de Fármacos , Electrocardiografía , Everolimus , Femenino , Estudios de Seguimiento , Humanos , Inmunosupresores/farmacología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Drug-eluting stents (DES) are routinely used in complex patients, but the impact of 1st- versus 2nd-generation DES on clinical outcomes has not been well described. This study aimed to assess the efficacy and safety of 2nd-generation (everolimus-eluting) DES compared to 1st-generation (sirolimus- and paclitaxel-eluting) DES in a selected, higher-risk population with complex clinical and angiographic features. METHODS: The study included 5693 consecutive patients with the presence of ≥ 1 predefined complex clinical and angiographic characteristic treated with either generation DES. Using propensity score matching, the clinical outcomes of 1076 patients treated with 2nd-generation DES were compared with the outcomes of a matched population treated with 1st-generation DES over 1-year follow-up. RESULTS: After matching, baseline clinical and angiographic characteristics were similar between groups. At 1-year follow-up, the rate of major adverse cardiac events was 9.4% with 2nd-generation DES and 11.3% with 1st-generation DES (p=0.16). There were no significant differences in the rates of death (3.2 vs. 4.0%, p=0.30), myocardial infarction (1.6 vs. 1.3%, p=0.57), target vessel revascularization (5.9 vs. 7.3%, p=0.17) or target lesion revascularization (4.4 vs. 5.0%, p=0.50). Definite stent thrombosis was less frequent with 2nd-generation DES (0.1 vs. 0.8%, p=0.011), as was definite or probable stent thrombosis (0.7 vs. 1.6%, p=0.040). CONCLUSION: In this propensity score matched patient population with complex features undergoing percutaneous coronary intervention, the use of 2nd-generation DES was associated with lower rates of stent thrombosis, and similar 1-year major adverse cardiac events compared to 1st-generation DES.
Asunto(s)
Stents Liberadores de Fármacos/normas , Infarto del Miocardio/cirugía , Vigilancia de la Población/métodos , Puntaje de Propensión , Trombosis/prevención & control , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Intervención Coronaria Percutánea/normas , Estudios Prospectivos , Trombosis/epidemiología , Resultado del TratamientoRESUMEN
Previous studies have shown a relation between female gender and adverse outcomes after percutaneous coronary intervention (PCI). The aim of this study was to determine whether there are differences in correlates between genders for these long-term adverse outcomes in patients with acute coronary syndromes. Gender differences were evaluated in the clinical outcomes of 6,929 consecutive patients with acute coronary syndromes from a large, contemporary PCI registry. Rates of major adverse cardiovascular events, defined as all-cause mortality, myocardial infarction, and target lesion revascularization at 1-year follow-up, are reported. Independent correlates of adverse outcomes were identified using multivariate proportional-hazards regression analysis. Women were older (p <0.001); had a higher prevalence of diabetes mellitus (p <0.001), systemic hypertension (p <0.001), chronic renal insufficiency (p = 0.02), peripheral arterial disease (p <0.001), and congestive heart failure (p <0.001); had lower body surface areas (p <0.001); and had higher body mass indexes (p <0.001). Acute coronary syndrome presentation in women tended to be unstable angina pectoris with Canadian Cardiovascular Society class III and IV symptoms, whereas men had more acute myocardial infarctions. At 1 year, the unadjusted rates of all-cause mortality (10.7% vs 7.5%, p <0.001) and major adverse cardiovascular events (16.4% vs 12.7%, p <0.001) were higher in women. There was a stark difference between the genders in independent correlates of mortality and major adverse cardiovascular events at 1 year. Moreover, the traditional correlates did not have the same impact in women as in men. In conclusion, although there are differences in clinical outcomes after PCI for women compared with men, there are different correlates for these adverse outcomes. These gender-based differences should be taken into account when women undergo contemporary PCI.
Asunto(s)
Síndrome Coronario Agudo/cirugía , Intervención Coronaria Percutánea , Complicaciones Posoperatorias/epidemiología , Síndrome Coronario Agudo/mortalidad , Anciano , Índice de Masa Corporal , Causas de Muerte , Distribución de Chi-Cuadrado , Diabetes Mellitus/epidemiología , District of Columbia/epidemiología , Electrocardiografía , Femenino , Insuficiencia Cardíaca/epidemiología , Humanos , Hipertensión/epidemiología , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Resultado del TratamientoRESUMEN
Paravalvular regurgitation is a common, potentially life-threatening complication of transcatheter aortic valve replacement. Previous studies report a 65%-94% rate of paravalvular leakage after transcatheter implantation, mostly of mild degree. The rate of significant (≥ +2) paravalvular regurgitation varies in large clinical trials, and is associated with worse clinical outcome. There is less agreement regarding the significance of mild regurgitation (grade 1+). There are anatomical and procedural correlates for paravalvular leak-most importantly, severe valve calcification, patient prosthetic mismatch, and device malposition. The following review details the current knowledge on paravalvular regurgitation after transcatheter aortic valve replacement, including diagnosis, correlates, clinical outcome, preventive and therapeutic strategies related to this complication.
Asunto(s)
Insuficiencia de la Válvula Aórtica/etiología , Estenosis de la Válvula Aórtica/terapia , Válvula Aórtica/fisiopatología , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hemodinámica , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/prevención & control , Insuficiencia de la Válvula Aórtica/terapia , Estenosis de la Válvula Aórtica/fisiopatología , Cateterismo Cardíaco/instrumentación , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Diseño de Prótesis , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
The incidence and prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR) have not been consistently studied. We aimed to assess the incidence and extent of myocardial injury after TAVR performed using transfemoral and transapical approaches. The clinical data from patients with aortic stenosis who underwent TAVR were retrospectively analyzed. The myocardial necrosis markers cardiac troponin I and creatine kinase (CK)-MB were assessed during hospitalization. Of the 150 TAVR patients, 95% and 50% had an abnormally elevated cardiac troponin I and CK-MB level, respectively. The transapical patients had significantly greater elevations of both cardiac troponin I (13.8 ± 14.0 vs 2.5 ± 5.8 ng/ml, p <0.001) and CK-MB (28.4 ± 24.2 vs 7.4 ± 8.6 ng/ml, p ≤0.001). On receiver operating curve analysis, postprocedural CK-MB (twofold increase) had high predictive power for 30-day mortality (area under the curve 0.85, p <0.001). Patients with high CK-MB levels had greater rates of postprocedural kidney injury (22% vs 6%, p = 0.026), in-hospital (22% vs 0%, p <0.001), 30-day (27% vs 1.5%, p <0.001), and 1-year mortality (41% vs 18%, p = 0.01). Baseline renal failure and no ß-blocker treatment on admission were independent predictors of an elevated postprocedural CK-MB level. In conclusion, a cardiac biomarker increase after TAVR was common and more frequent among transapical access patients. A twofold increase (>7 ng/ml) in CK-MB after transfemoral TAVR was a surrogate for poor long-term outcomes.