RESUMO
OBJECTIVES: To determine whether in-hospital outcome differs for transferred patients with ST-segment elevation myocardial infarction (STEMI) presenting during business (ON) hours vs. after (OFF) hours. BACKGROUND: Door-to-device (DTD) time is a prognostic factor in patients with STEMI and is longer during OFF hours. However, the in-hospital mortality is controversial. METHODS: This registry study included 786 consecutive patients with STEMI referred for primary percutaneous coronary intervention to a tertiary care center with an on-site cardiac catheterization team 24 hrs a day/7 days (24/7) a week. ON hours were defined as weekdays 8 a.m. to 5 p.m., while OFF hours were defined as all other times, including holidays. The primary outcomes were in-hospital death, reinfarction, and length of stay (LOS). RESULTS: ON hours (29.5%, n = 232) and OFF hours (70.5%, n = 554) groups had similar demographic and baseline characteristics. A significantly higher proportion of patients presenting ON hours had a DTD time ≤120 min compared to OFF hours patients (32.6% vs. 22.1%, P = 0.007). The rates of in-hospital death (8.2% vs. 6%), reinfarction (0% vs. 1.1%), and mean LOS (5.7 ± 6 vs. 5.7 ± 5) were not significantly different in the ON vs. OFF hours groups, all P = nonsignificant. CONCLUSION: In a tertiary care center with an on-site cardiac catheterization team 24/7, there are no differences in in-hospital outcomes of transferred patients with STEMI during ON vs. OFF hours.
Assuntos
Plantão Médico , Cateterismo Cardíaco , Serviço Hospitalar de Cardiologia , Infarto do Miocárdio/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde , Transferência de Pacientes , Admissão e Escalonamento de Pessoal , Qualidade da Assistência à Saúde , Idoso , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Distribuição de Qui-Quadrado , Cuidados Críticos , District of Columbia , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Razão de Chances , Guias de Prática Clínica como Assunto , Recidiva , Encaminhamento e Consulta , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Carga de TrabalhoRESUMO
OBJECTIVES: To characterize the clinical and angiographic characteristics of patients with collateralization from the internal mammary artery to the iliac artery. BACKGROUND: The use of the internal mammary arteries for coronary revascularization has become the standard of care in coronary artery bypass grafting (CABG). However, in patients with aortoiliac disease, the internal mammary arteries may become a major collateral route to the lower extremities. METHODS: A case series of 15 patients admitted for diagnostic coronary angiography were retrospectively identified, who were observed to have collateral flow from one or both internal mammary artery(ies) to an occluded or stenotic iliac artery. RESULTS: The mean age was 63.2 +/- 11.2 years; eight were men (53.3%). Coronary angiography was done as a perioperative evaluation for peripheral vascular surgery in three patients (20%) and was done because of cardiac symptoms or a positive thallium scan in 12 (80%). The finding that the mammary artery collateralized the iliac artery led to major treatment changes in all patients, seven (46.6%) who required CABG. In five patients (33%), use of one or both internal mammary artery(ies) for coronary grafts was avoided. CABG was deferred in one patient, whereas in another, percutaneous intervention in both iliac arteries preceded CABG using both mammary arteries. There was no incidence of postoperative acute lower extremity ischemia. CONCLUSIONS: Selective angiographic visualization of the internal mammary artery is an essential part of the preoperative evaluation in patients with severe peripheral vascular disease undergoing CABG.
Assuntos
Arteriopatias Oclusivas/complicações , Circulação Colateral , Doença da Artéria Coronariana/cirurgia , Artéria Ilíaca/fisiopatologia , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Extremidade Inferior/irrigação sanguínea , Idoso , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Constrição Patológica , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Artéria Ilíaca/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Medição de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Several patients undergoing permanent pacemaker (PPM) implantation/upgrade present with difficult access due to sub- or total central vein occlusion. Our institution has used the endovascular approach to recanalize central veins to allow for subsequent PPM implantation. Here we aim to describe the feasibility and safety of using this approach to allow for PPM implantation/upgrade. METHODS: From October 2006 to November 2010, 50 consecutive patients who underwent central vein recanalization prior to PPM implantation were included in this analysis. RESULTS: The population's mean age was 70 years, with a high rate of comorbidities including chronic renal failure (52.0%), congestive heart failure (64.0%), diabetes (33.3%) and peripheral vascular disease (36.0%). The endovascular recanalization procedure was performed via femoral access in all patients; however adjuvant brachial access was required in 13 cases and subclavian vein in one. Subclavian vein (74.5%) followed by innominate vein (21.6%) were the most common locations/target for recanalization. Successful vein recanalization followed by successful PPM implantation/upgrade was achieved in 48 patients (96.0%) without peri-procedural complications. Two patients died during the hospitalization, one due to severe respiratory failure and a second due to complicated end-stage renal disease, although neither was related to the endovascular procedure. No other event, including myocardial infarction, cerebral-vascular accident, bleeding/transfusion, or renal failure was identified. CONCLUSIONS: This study proved the feasibility and safety of the endovascular approach to recanalize central veins in patients with poor vascular access to allow for further PPM implantation/upgrade.
Assuntos
Cateterismo Venoso Central , Procedimentos Endovasculares , Marca-Passo Artificial , Doenças Vasculares/terapia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/mortalidade , Comorbidade , Constrição Patológica , District of Columbia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/mortalidade , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Veia Femoral/diagnóstico por imagem , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial/efeitos adversos , Flebografia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents , Resultado do Tratamento , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/mortalidadeRESUMO
Clinical and angiographic risk factors associated with adverse outcomes after percutaneous coronary intervention (PCI) have been included in previous validated risk scores. Complications after PCI are known to increase mortality and morbidity but have not been included in any model. Records of 6,932 consecutive patients who underwent PCI from 2000 to 2005 were reviewed. Patients presenting with cardiogenic shock were excluded. Logistic regression and bootstrap methods were used to build an integer risk score for estimating risk of death at 1 year after PCI using baseline, angiographic, and procedural characteristics and postprocedural complications. This risk score was validated in a set of consecutive patients who underwent PCI from 2006 to 2007. The following 8 variables were significantly correlated with outcome: older age, history of diabetes mellitus, chronic renal failure, heart failure, left main coronary artery disease, lower baseline hematocrit, greater hematocrit decrease after PCI, and Thrombolysis In Myocardial Infarction grade <3 flow after PCI. In the validation population (n = 973), average receiver operating characteristic curve area was 0.836. In conclusion, we developed and validated a simple integer risk score, including postprocedural variables that closely predict long-term mortality after PCI. This model emphasizes the significant impact of complications occurring after PCI on long-term outcomes.
Assuntos
Angioplastia Coronária com Balão , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/terapia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
The Registry Experience at the Washington Hospital Center with Drug-Eluting Stents (REWARDS) study includes unselected patients with coronary artery disease treated with sirolimus-eluting stents (SESs; n = 2,392) or paclitaxel-eluting stents (PES; n = 1,119). This study aimed to examine the long-term safety profile of the 2 stents in a "real-world" population, especially in relation to stent thrombosis, and to compare differences in the diabetic cohort. Patients were followed for 3 years with regard to major adverse cardiac events (MACEs), including death, Q-wave myocardial infarction, and target lesion revascularization. Rates of stent thrombosis were also studied. Baseline characteristics were similar between stents. Although MACE rates at 3 years were similar (SES 28.1% vs PES 28.9%, p = 0.62), there was a significant difference in unadjusted rates of target lesion revascularization (SES 15.6% vs PES 12.6%, p = 0.03), death (SES 15.7% vs PES 19.0%, p = 0.02), and Q-wave myocardial infarction (SES 0.8% vs PES 2.1%, p = 0.003). After multivariable Cox regression to adjust for confounders, there was no significant difference in overall MACEs. Incidence of stent thrombosis was higher in the SES group (SES 2.2% vs PES 1.6%, p = 0.22), but this was not statistically significant (hazard ratio 1.6, 95% confidence interval 0.8 to 2.9, p = 0.17). Overall, diabetics had a higher MACE rate, but there was no difference between insulin- and noninsulin-dependent diabetics. In conclusion, at 3 years, PES and SES achieved similar results in MACEs and stent thrombosis. This should foster confidence that SES or PES can be compared to second-generation drug-eluting stents without concerns for safety or efficacy.
Assuntos
Doença da Artéria Coronariana/terapia , Trombose Coronária/etiologia , Complicações do Diabetes , Stents Farmacológicos/efeitos adversos , Imunossupressores/administração & dosagem , Paclitaxel/administração & dosagem , Sirolimo/administração & dosagem , Idoso , Angioplastia Coronária com Balão , Estudos de Coortes , Doença da Artéria Coronariana/etiologia , Feminino , Seguimentos , Humanos , Imunossupressores/efeitos adversos , Masculino , Pessoa de Meia-Idade , Paclitaxel/efeitos adversos , Sistema de Registros , Sirolimo/efeitos adversos , Resultado do TratamentoRESUMO
Transcatheter aortic valve implantation (TAVI) without replacement requires precise knowledge of the anatomic dimensions and physical characteristics of the peripheral vasculature and aortic valve annulus at the insertion of the aortic valve leaflet and root at the level of the sinus of Valsalva. Multislice computed tomography (CT) allows detailed and precise assessment of the anatomic variables. Noncardiovascular structures are also amenable to assessment by CT. Of the 394 patients screened for TAVI, 259 (65.7%) had non-contrast CT to evaluate chest anatomy and contrast CT to evaluate ilio-femoral anatomy. Significant noncardiac findings were defined as those requiring immediate evaluation or intervention or additional clinical or radiologic follow-up. Noncardiovascular findings known before CT were not included. Of the 259 patients, 105 (40.5%) were men. The mean age was 82.3 +/- 8.1 years. New, significant noncardiovascular findings were found in 89 (34.3%) and malignancy in 11 (4.2%) patients. Insignificant noncardiovascular findings were identified in 222 patients (85.7%). Signs of fluid retention were noted on CT in 105 patients (40.5%), with pleural effusion in 100 (38.6%), ascites in 17 (6.5%), and pericardial effusion in 14 (5.4%). Important peripheral vascular disease was found in 98 patients (37.8%), resulting in exclusion of 49 (19.1%) from TAVI using the transfemoral approach. An aortic aneurysm was found in 10 patients (3.8%) and a "porcelain" aorta (heavily calcified ascending aorta) in 19 (7.3%). In conclusion, malignancy and other noncardiovascular abnormalities are often found in patients who undergo CT for evaluation for TAVI. Populations must be meticulously examined to ensure that important findings are not missed.