Virtual histology intravascular ultrasound assessment of cardiac allograft vasculopathy from 1 to 20 years after heart transplantation.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the main cause of graft loss and death in heart transplant (HTx) recipients surviving >1 year. There is a dual etiology for coronary disease in HTx: classic atherosclerosis and an immunologically mediated disease. Intravascular ultrasound (IVUS) is highly sensitive for CAV detection; however, gray-scale IVUS is of limited value for identification of specific plaque components. We sought to characterize graft coronary artery disease by means of IVUS-virtual histology (IVUS-VH) at different time-points of follow-up and to correlate plaque composition with clinical factors. METHODS: In our study we included 67 patients, who were 7.6 +/- 5.7 years post-HTx. IVUS gray-scale evaluation was performed on all patients. IVUS-VH analysis was done in those patients showing intimal thickening >0.5 mm at the three more significant lesions (three cross-sections for each) of the left anterior descending artery. RESULTS: IVUS-VH analysis was obtained done on 58 patients (86.5%). We found a significant correlation between time of HTx and IVUS gray-scale parameters (plaque area and plaque burden), with both increasing over time. We also found a significant correlation between time and IVUS-VH-derived plaque components, necrotic core and calcium, which increased with time, and fibrous and fibrofatty components, both decreased at follow-up. IVUS-VH results were also related to donor age and cardiovascular risk factors. CONCLUSIONS: We observed a time-related change in IVUS-VH-derived plaque composition. Necrotic core and calcium, typical atheromatous components, become more prevalent with time after HTx, especially when influenced by cardiovascular risk factors. The presence of a necrotic core in the early stages was linked to older donor age.

[Prospective use of an intravascular ultrasound-derived minimum lumen area cut-off value in the assessment of intermediate left main coronary artery lesions]. / Aplicación prospectiva de un valor de corte de área luminal mínima por ecografía intravascular en la evaluación de lesiones intermedias del tronco.

BACKGROUND AND OBJECTIVES: Angiographic assessment of the severity of intermediate lesions in the left main coronary artery (LMCA) is subject to significant limitations. Intravascular ultrasound (IVUS) can provide accurate measurement, but there is no agreement on the minimum lumen cross-sectional area (MLA) that indicates significant disease. The aim of this study was to determine the long-term safety of applying a cut-off value of 6 mm2 for the MLA in the LMCA. METHODS: The study included patients with intermediate lesions (i.e., 25-50%) in unprotected LMCAs, with no previous evidence of associated ischemia. An IVUS examination was carried out and revascularization was indicated when the MLA was < or =6 mm2. RESULTS: In total, 79 patients were recruited between 2000-2005. In 31 (39%), the MLA was < or =6 mm2, and they underwent LMCA revascularization; in the remaining 48 (61%), the MLA was >6 mm2, and patients either underwent angioplasty for other lesions (n=37) or continued medical treatment (n=11). In a follow-up period of 40 [17] months, four patients (8.3%) died from heart disease, all of whom had an MLA between 9-10 mm2 in the baseline study. Revascularization of the LMCA was necessary in only two patients (4.2%), both of whom had elective surgery more than 2 years after the initial study. CONCLUSIONS: Intravascular ultrasound assessment of intermediate LMCA lesions using an MLA cut-off value of 6 mm2 appears safe over the long term provided the clinical and angiographic criteria applied to patient selection are similar to those used in this study.

Aplicación prospectiva de un valor de corte de área luminal mínima por ecografía intravascular en la evaluación de lesiones intermedias del tronco / Prospective use of an intravascular ultrasound-derived minimum lumen area cut-off value in the assessment of intermediate left main coronary artery lesions

Introducción y objetivos. La angiografía presenta limitaciones importantes para definir la severidad de las lesiones intermedias del tronco común. La ecografía endovascular (EEV) permite realizar una evaluación precisa, pero no hay consenso respecto a los valores de área luminal mínima (ALM) que indican significación. El objetivo de este estudio es evaluar la seguridad a largo plazo de la aplicación de un valor de corte de 6 mm2 para el ALM en el tronco. Métodos. Se ha incluido a pacientes con lesiones intermedias (25-50%) de tronco no protegido, sin datos previos indicativos de isquemia atribuible. Se realizó estudio con EEV y se indicó revascularización en los pacientes con ALM ≤ 6 mm2. Resultados. En el período 2000-2005 se ha incluido a 79 pacientes, en 31 (39%) el ALM fue ≤ 6 mm2 y recibieron revascularización del tronco, en los restantes 48 (61%) el ALM fue > 6 mm2 y sólo se actuó sobre otras lesiones (n = 37) o continuaron con tratamiento médico (n = 11). En un seguimiento de 40 ± 17 meses se han producido 4 muertes cardiacas (8,3%), que ocurrieron en casos con un ALM de 9-10 mm2 en el estudio basal. Sólo en 2 casos (4,2%) fue preciso efectuar procedimientos de revascularización del tronco que consistieron en cirugías electivas tras más de 2 años del estudio inicial. Conclusiones. La evaluación con EEV de las lesiones intermedias de tronco y la consideración de un valor de corte de 6 mm2 para el ALM resulta segura a largo plazo, siempre que se consideren unos criterios clinicoangiográficos de aplicabilidad como los considerados en este estudio (AU)

Background and objectives. Angiographic assessment of the severity of intermediate lesions in the left main coronary artery (LMCA) is subject to significant limitations. Intravascular ultrasound (IVUS) can provide accurate measurement, but there is no agreement on the minimum lumen cross-sectional area (MLA) that indicates significant disease. The aim of this study was to determine the long-term safety of applying a cut-off value of 6 mm2 for the MLA in the LMCA. Methods. The study included patients with intermediate lesions (i.e., 25­50%) in unprotected LMCAs, with no previous evidence of associated ischemia. An IVUS examination was carried out and revascularization was indicated when the MLA was ≤6 mm2. Results. In total, 79 patients were recruited between 2000­2005. In 31 (39%), the MLA was ≤6 mm2, and they underwent LMCA revascularization; in the remaining 48 (61%), the MLA was >6 mm2, and patients either underwent angioplasty for other lesions (n=37) or continued medical treatment (n=11). In a follow-up period of 40 [17] months, four patients (8.3%) died from heart disease, all of whom had an MLA between 9­10 mm2 in the baseline study. Revascularization of the LMCA was necessary in only two patients (4.2%), both of whom had elective surgery more than 2 years after the initial study. Conclusions. Intravascular ultrasound assessment of intermediate LMCA lesions using an MLA cut-off value of 6 mm2 appears safe over the long term provided the clinical and angiographic criteria applied to patient selection are similar to those used in this study (AU)

Seguridad a largo plazo de los stents recubiertos. El fenómeno de la trombosis tardía / Long-term safety of drug-eluting stents. The late thrombosis phenomenon

La aparición de los stents liberadores de fármacos ha supuesto uno de los grandes hitos en el intervencionismo percutáneo de la cardiopatía isquémica y ha logrado en muy poco tiempo una aceptación unánime en todo el mundo y un crecimiento exponencial en el número de unidades implantadas. Después de varios años de un entusiasmo excesivo en los que se ha constatado, sin ninguna duda, un beneficio claro sobre el talón de Aquiles de la angioplastia coronaria, como es el problema de la reestenosis, empiezan a surgir ciertas dudas acerca de la seguridad a largo plazo de estos dispositivos, fundamentadas en la aparición de casos tardíos de trombosis intra-stent, en ocasiones muy alejados en el tiempo, con consecuencias adversas para los pacientes (AU)

The introduction of drug-eluting stents is regarded as one of the landmarks of percutaneous coronary intervention for ischemic heart disease. In a very short time, they were universally accepted throughout the world and the number of units implanted grew exponentially. After several years of excessive enthusiasm, during which these stents demonstrated, without doubt, clear benefits for the Achilles’ heel of coronary angioplasty, namely the problem of restenosis, a number of doubts about the long-term safety of these devices began to arise. These stemmed from the appearance of cases of late intrastent thrombosis, sometimes occurring in a much later time period, which had adverse consequences for patients (AU)

[Two-year clinical follow-up in 200 patients receiving sirolimus-eluting stents in lesions at a high risk of restenosis]. / Seguimiento clínico a 2 años de 200 pacientes tratados con stent liberador de rapamicina en lesiones de alto riesgo de reestenosis.

INTRODUCTION AND OBJECTIVES: Sirolimus-eluting stents (SESs) have been shown to reduce the rate of restenosis significantly in all types of coronary lesion. However, reports of late cases of thrombosis and restenosis have raised questions about long-term outcome in patients treated with these stents. Our aim was to evaluate long-term outcome in patients undergoing SES placement in lesions at a high risk of restenosis. PATIENTS AND METHOD: Since SESs became available, we have used them to treat lesions at risk of restenosis. We studied clinical outcomes in consecutive patients treated with SESs who were followed up for more than 2 years. RESULTS: The study included 200 patients (age 60[11] years, 22% diabetics) who were treated between June 2002 and April 2003 for 309 lesions: 16% were total occlusions, 16.8% in-stent restenoses, 28% diffuse lesions, and 30% small-vessel lesions. The total stent length per patient was 29 (16) mm and the mean diameter was 2.78 (0.27) mm. In a mean clinical follow-up period of 29 (3.2) months (range 24-34 months), there were four deaths, two (1%) of which were cardiac, four (2%) non-fatal infarctions, four (2%) in-stent thromboses (all occurred late, at 3, 7, 26 and 31 months), four (2%) cases requiring target lesion revascularization (at 3, 5, 14 and 15 months), and six (3%) requiring revascularization of a new lesion. CONCLUSIONS: Long-term follow-up of patients undergoing SES placement in lesions at a high risk of restenosis revealed a very low restenosis rate. However, the incidence of late thrombosis appeared to be elevated and warrants further evaluation in larger studies.

Seguimiento clínico a 2 años de 200 pacientes tratados con stent liberador de rapamicina en lesiones de alto riesgo de reestenosis / Two-year clinical follow-up in 200 patients receiving sirolimus-eluting stents in lesions at a high risk of restenosis

Introducción y objetivos. Los stents de rapamicina (SR) han demostrado reducir la tasa de reestenosis en múltiples estudios, pero se han descrito algunos casos de reestenosis y trombosis tardías que proyectan dudas sobre sus resultados a largo plazo (> 2 años). Nos planteamos estudiar retrospectivamente la evolución a largo plazo de pacientes tratados con SR en lesiones de alto riesgo de reestenosis. Pacientes y método. Desde su introducción, hemos utilizado SR en los casos con lesiones de mayor riesgo de reestenosis. Estudiamos la evolución clínica de los pacientes en los que se implantaron SR y que cuentan con un seguimiento clínico superior a 2 años. Resultados. Se estudió a 200 pacientes (edad 60 ± 11 años, un 22% diabéticos) tratados entre junio de 2002 y abril de 2003 en 309 lesiones: un 16%, oclusiones totales; un 16,8%, reestenosis intra-stent; un 28%, difusas, y un 30%, en vaso pequeño. La longitud total de stent por paciente fue de 29 ± 16 mm y el diámetro del stent, de 2,78 ± 0,27 mm. En el seguimiento clínico de 29 ± 3,2 meses se produjeron los siguientes eventos: 4 muertes, de las que 2 (1%) fueron cardiacas; 4 infartos (2%); 4 trombosis de stent documentadas (2%), todas tardías a los 3, 7, 26 y 31 meses; 4 casos (2%) de revascularización por reestenosis del segmento tratado a los 3, 5, 14 y 15 meses, y 6 casos (3%) de revascularización de otra lesión. Conclusiones. La evolución a largo plazo de los pacientes con SR en lesiones de alto riesgo reestenótico muestra una tasa de reestenosis clínica muy baja. La incidencia de trombosis tardía parece resultar algo elevada y debería ser evaluada en series más amplias

Introduction and objectives. Sirolimus-eluting stents (SESs) have been shown to reduce the rate of restenosis significantly in all types of coronary lesion. However, reports of late cases of thrombosis and restenosis have raised questions about long-term outcome in patients treated with these stents. Our aim was to evaluate long-term outcome in patients undergoing SES placement in lesions at a high risk of restenosis. Patients and method. Since SESs became available, we have used them to treat lesions at risk of restenosis. We studied clinical outcomes in consecutive patients treated with SESs who were followed up for more than 2 years. Results. The study included 200 patients (age 60[11] years, 22% diabetics) who were treated between June 2002 and April 2003 for 309 lesions: 16% were total occlusions, 16.8% in-stent restenoses, 28% diffuse lesions, and 30% small-vessel lesions. The total stent length per patient was 29 (16) mm and the mean diameter was 2.78 (0.27) mm. In a mean clinical follow-up period of 29 (3.2) months (range 24-34 months), there were four deaths, two (1%) of which were cardiac, four (2%) non-fatal infarctions, four (2%) in-stent thromboses (all occurred late, at 3, 7, 26 and 31 months), four (2%) cases requiring target lesion revascularization (at 3, 5, 14 and 15 months), and six (3%) requiring revascularization of a new lesion. Conclusions. Long-term follow-up of patients undergoing SES placement in lesions at a high risk of restenosis revealed a very low restenosis rate. However, the incidence of late thrombosis appeared to be elevated and warrants further evaluation in larger studies

Coronary angiography with flat panel digital detectors significantly increases the sensitivity for calcium detection in relation to conventional fluoroscopy: comparison of both systems with intravascular ultrasound.

OBJECTIVE: To compare the sensitivity and specificity for coronary calcium detection of two fluoroscopic systems: 1) conventional system based on image intensifier chains (CONV); and 2) flat panel digital detector (FPDD) system, using intravascular ultrasound (IVUS) as the gold standard. BACKGROUND: Coronary calcification represents advanced atherosclerotic disease and has implications during coronary interventions. Angiography has been reported to have low sensitivity for calcium detection compared with IVUS. METHODS: Lesion calcification was assessed by two different fluoroscopic systems (FPDD and CONV), and by IVUS. RESULTS: In two consecutive periods, a total of 200 consecutive patients were included, 100 in each group. Clinical characteristics were similar, without significant differences between groups. In the CONV group, IVUS detected calcium in 77% of cases, and angiography in 32%. Sensitivity was 41.6% and specificity 91.3%. In the FPDD group, IVUS reported calcification in 79% of patients, and angiography in 57%. Sensitivity was 72% (p < 0.0001 for comparison with CONV) and specificity was 90.4%. CONCLUSION: The new fluoroscopic systems, based on FPDD, considerably increase the sensitivity for calcium detection without detrimental effect on specificity.

[Treatment of lesions with a high risk of stenosis. Comparative study in 300 patients of rapamycin- and Paclitaxel-eluting polymer-based stents, and bare metal stents]. / Tratamiento de lesiones con alto riesgo de reestenosis. Estudio comparativo en 300 pacientes del stent liberador de rapamicina, el stent con polímero liberador de paclitaxel y el stent convencional.

INTRODUCTION AND OBJECTIVES: Rapamycin- and taxol-eluting stents have been shown to reduce restenosis, but there are no large-scale studies of their usefulness in lesions with a high risk of restenosis, or of the relative merits of the two devices. This prospective study compared their safety and efficacy in lesions with a high risk of restenosis. PATIENTS AND METHOD: We included consecutive patients with lesions to treat that met at least one of the following criteria: a) in-stent restenosis; b) diffuse (>20 mm) restenosis; c) small vessel (< or =2.5 mm) restenosis; or d) total occlusion. Patients received different devices along three consecutive study periods: bare metal (conventional) stents, sirolimus-eluting (rapamycin) stents and paclitaxel-eluting (taxol) stents. RESULTS: One hundred patients in each group were included, for a total of 300 patients. In the sirolimus group, after 8.5+/-2 months of follow-up, there were 2 late thromboses (2%) and only 1 patient (1%) required target lesion revascularization. In the paclitaxel group 2 patients (2%) had in-hospital stent thrombosis (1 acute, 1 subacute), and after 9+/-2.5 months of follow-up only 1 patient (1%) needed target lesion revascularization. In the conventional group, after 8+/-2 months of follow-up, there was 1 subacute thrombosis (1%) and 15 patients (15%) had clinical restenosis requiring target lesion revascularization. Event-free survival curves were significantly better with drug-eluting stents (P<.01 vs conventional stents). CONCLUSION: Rapamycin- and taxol-eluting stents were safe for lesions with a high risk of restenosis. These stents were associated with a lower rate of target lesion revascularization during follow-up compared to bare metal stents.

Comparison of C-reactive protein levels after coronary stenting with bare metal versus sirolimus-eluting stents.

We evaluated C-reactive protein increases after implantation of bare metal stents in 200 patients and sirolimus-eluting stents in 100 patients. The magnitude of change in C-reactive protein was comparable between groups. Clinical follow-up showed a relation between the postprocedural C-reactive protein increase and outcome that was significant in the bare metal stent group, which accounted for the most of events, but not in the sirolimus-eluting stent group.

Tratamiento de lesiones con alto riesgo de reestenosis. Estudio comparativo en 300 pacientes del stent liberador de rapamicina, el stent con polímero liberador de paclitaxel y el stent convencional / Treatment of lesions with a high risk of stenosis. Comparative study in 300 patients of rapamycinand paclitaxel-eluting polymer-based stents, and bare metal stents

Introducción y objetivos. Se ha demostrado que los stents con rapamicina y paclitaxel reducen la reestenosis, pero no hay estudios amplios en contextos lesionales de alto riesgo ni estudios que comparen la eficacia de ambos. En este estudio prospectivo nos planteamos comparar su eficacia en lesiones de alto riesgo reestenótico. Pacientes y método. Se incluyó a pacientes consecutivos con angioplastia sobre lesiones de las cuales alguna reuniera al menos una de las siguientes características: a) reestenosis intra-stent; b) difusa (> 20 mm); c)vaso pequeño (≤ 2,5 mm), y d) oclusión total. Los pacientes fueron tratados de forma distinta, en 3 períodos consecutivos, mediante stent convencional, stent de rapamicina y stent de taxol. Resultados. Se ha incluido a 300 pacientes, 100 encada grupo. En el grupo de stents de rapamicina, con un seguimiento de 8,5 ± 2 meses, se produjeron 2 (2%)trombosis tardías y un (1%) caso de revascularización dela lesión tratada. En el grupo de stents de taxol se produjeron2 (2%) trombosis (aguda y subaguda) en el hospital, y en un seguimiento de 9 ± 2,5 meses ocurrió 1muerte no cardíaca (1%) y 1 paciente (1%) fue revascularizado en la lesión tratada. En el grupo de stents convencionales, con un seguimiento de 8 ± 2 meses, hubo 1trombosis subaguda (1%) y 15 casos de reestenosis clínica con revascularización (15%). Las curvas de supervivencia libre de eventos fueron significativamente mejores con los stents recubiertos (p < 0,01 en comparación con el convencional).Conclusión. La utilización de stents con rapamicina y paclitax el en lesiones de alto riesgo para reestenosis fue segura, y la necesidad de una nueva revascularización durante el seguimiento fue comparablemente baja con ambos en relación con la del stent convencional

Introduction and objectives. Rapamycin- and taxoleluting stents have been shown to reduce restenosis, but there are no large-scale studies of their usefulness in lesions with a high risk of restenosis, or of the relative merits of the two devices. This prospective study compared their safety and efficacy in lesions with a high risk of restenosis. Patients and method. We included consecutive patients with lesions to treat that met at least one of the following criteria: a) in-stent restenosis; b) diffuse (>20 mm) restenosis; c) small vessel (≤2,5 mm) restenosis; or d)total occlusion. Patients received different devices along three consecutive study periods: bare metal (conventional)stents, sirolimus-eluting (rapamycin) stents and paclitaxel-eluting (taxol) stents. Results. One hundred patients in each group were included,for a total of 300 patients. In the sirolimus group, after 8.5±2 months of follow-up, there were 2 late thromboses(2%) and only 1 patient (1%) required target lesion revascularization. In the paclitaxel group 2 patients (2%)had in-hospital stent thrombosis (1 acute, 1 subacute),and after 9±2.5 months of follow-up only 1 patient (1%)needed target lesion revascularization. In the conventional group, after 8±2 months of follow-up, there was 1 subacute thrombosis (1%) and 15 patients (15%) had clinical restenosis requiring target lesion revascularization. Event-free survival curves were significantly better with drug-eluting stents (P<.01 vs conventional stents).Conclusion. Rapamycin- and taxol-eluting stents were safe for lesions with a high risk of restenosis. These stents were associated with a lower rate of target lesion revascularization during follow-up compared to bare metal stents

[Sirolimus-eluting stents to treat lesions with a high risk of restenosis. Six-month clinical follow-up in the first 100 patients]. / Stent liberador de rapamicina en el tratamiento de lesiones coronarias con alto riesgo de reestenosis. Seguimiento clínico a 6 meses de los primeros 100 pacientes.

INTRODUCTION: Sirolimus-eluting stents have been shown to be effective in de-novo coronary lesions, reducing restenosis strikingly in a subset of lesions with a low or moderate risk of restenosis. We decided to assess their usefulness in lesions with a high risk of restenosis. PATIENTS AND METHOD: We included consecutive patients with lesions that met at least one of the following criteria: a) in-stent restenosis; b) diffuse lesion (>20 mm); c) small vessel (< or =2.5 mm), and d) total occlusion. RESULTS: Between June 2002 to December 2002, 100 patients were included (61 [11] years, 84% men, 21% with diabetes). In all, 154 lesions were treated (34% diffuse lesions, 36% in small vessels, 20% in-stent restenosis and 20% occlusions). An average of 1.6 (0.7) stents were implanted per patient. Mean diameter was 2.74 (0.26) mm, mean length was 21 (8.5) mm and total stent length per patient was 33 (16) mm. The acute success rate was 98%. After the procedure 2 (2%) non-Q-wave infarctions were diagnosed. No episodes of acute or subacute thrombosis occurred. During a follow-up period of 8.5 (2) months (range 6-12 months) there were two (2%) late thromboses, one of which caused an infarction. Target lesion revascularization was required in 3 patients (3%), two of whom were the patients with late thrombosis. CONCLUSIONS: Sirolimus-eluting stents can be used in lesions with a high risk of restenosis. The rate of thrombosis was low, and the use of these stents was associated with a strikingly low rate of target lesion revascularization during follow-up.

Stent liberador de rapamicina en el tratamiento de lesiones coronarias con alto riesgo de reestenosis. Seguimiento clínico a 6 meses de los primeros 100 pacientes / Sirolimus-Eluting Stents to Treat Lesions With a High Risk of Restenosis. Six-Month Clinical FollowUp in the First 100 Patients

Introducción y objetivos. Los stents con rapamicina han demostrado reducir drásticamente la reestenosis en lesiones con un riesgo reestenótico entre ligero y moderado. No existen estudios amplios que evalúen su comportamiento en contextos lesionales de alto riesgo. Nos planteamos conocer el posible impacto de su empleo en este tipo de lesiones. Pacientes y método. Se incluyó a pacientes consecutivos con indicación de angioplastia con alguna lesión que reuniera al menos una de las siguientes características: a) reestenosis intra-stent; b) difusa (> 20 mm); c) vaso pequeño ( 2,5 mm), y d) oclusión total. Resultados. Entre junio y diciembre de 2002 se incluyó a 100 pacientes (61 ñ 11 años; un 84 por ciento varones; un 21 por ciento diabéticos) que tenían 154 lesiones tratadas (un 34 por ciento difusas, un 36 por ciento en un vaso pequeño, un 20 por ciento reestenosis intra-stent y un 20 por ciento oclusiones). Se implantaron 1,6 ñ 0,7 stents/paciente, con un diámetro de 2,74 ñ 0,26 mm, una longitud de 21 ñ 8,5 mm y una longitud total stent/paciente de 33 ñ 16 mm. Se obtuvo un éxito inmediato en el 98 por ciento. Se produjeron 2 infartos sin onda Q (2 por ciento) tras el procedimiento. No hubo ningún caso de trombosis agudas ni subagudas. Durante el seguimiento de 8,5 ñ 2 meses (rango, 6-12 meses) se produjeron 2 trombosis tardías (2 por ciento), a los 3 y 7 meses, una de las cuales ocasionó un infarto. Se efectuó revascularización de la lesión tratada en 3 casos (3 por ciento), 2 de los cuales correspondieron a las trombosis tardías. Conclusiones. La utilización de stents con rapamicina en lesiones de alto riesgo para reestenosis fue segura y la necesidad de nueva revascularización en el seguimiento fue notablemente baja (AU)

[Importance of severe lesions left untreated in patients with acute coronary syndromes and angioplasty of the culprit lesion]. / Importancia de las lesiones severas no tratadas en pacientes con síndrome coronario agudo y angioplastia de la lesión causante.

INTRODUCTION AND OBJECTIVES: Patients with acute coronary syndromes may have significantly stenotic nonculprit lesions that do not show complex lesion morphology. We investigated whether these lesions were prone to become unstable since they exist within a prothrombotic and inflammatory systemic milieu. PATIENTS AND METHOD: We evaluated the clinical course of 150 patients after successful angioplasty of a culprit lesion: 75 patients with a severely stenotic but uncomplicated nonculprit lesion (group A) and 75 patients without these lesions (group B). RESULTS: In group A, 1 patient (1.3%) required angioplasty of an initially nonculprit lesion, and in group B, 2 patients (2.6%) died in cardiogenic shock. After 1 year of follow-up, in group A, 4 patients (5.3%) died (cardiac deaths), 1 patient (1.3%) had a myocardial infarction, and 10 patients (13.3%) underwent a repeat revascularization procedure, which in 6 cases (8%) was angioplasty of an initially nonculprit lesion. In all 6 patients with angioplasty of the initially nonculprit lesion, revascularization was done within the first 4 months and was indicated for unstable angina. In group B, 1 patient (1.3%) died (noncardiac death) and 2 patients (2.6%) underwent a repeat revascularization procedure because of restenosis. Survival curves were significantly different between both groups. Belonging to group A was the only independent predictor for events, and within this group location of the lesion in the left anterior descending artery was the main predictor. CONCLUSIONS: The presence of nonculprit lesions of uncomplicated morphology at the time of a percutaneous revascularization procedure for a culprit lesion in patients with acute coronary syndrome is a short- and middle-term predictor of a moderate rate of recurrent events when these initially innocuous lesions become unstable.

Importancia de las lesiones severas no tratadas en pacientes con síndrome coronario agudo y angioplastia de la lesión causante / Importance of severe lesions left untreated in patients with acute coronary syndromes and angioplasty of the culprit lesion

Introducción y objetivos. Los pacientes con síndrome coronario agudo pueden presentar lesiones coronarias no causantes que pueden ser severas y sin morfología compleja. Evaluamos si, a corto plazo, estas lesiones son proclives a la inestabilización al encontrarse en un entorno sistémico protrombótico e inflamatorio. Pacientes y método. Evaluamos la evolución clínica de 150 pacientes sometidos a angioplastia (ACTP) de la lesión causante, 75 pacientes (grupo A) con lesiones no causantes gravemente estenóticas no complicadas (LNC) y otros 75 pacientes (grupo B) con ausencia de estas lesiones. Resultados. En el grupo A, un paciente (1,3 por ciento) precisó ACTP de una LNC y en el grupo B, 2 pacientes (2,6 por ciento) fallecieron por shock cardiogénico. Al cabo de un año de seguimiento, en el grupo A, 4 pacientes (5,3 por ciento) murieron por causa cardíaca, uno (1,3 por ciento) sufrió un infarto y 10 (13,3 por ciento) precisaron revascularización, en 6 casos ACTP sobre LNC. Estos 6 procedimientos se efectuaron en los primeros 4 meses por angina inestable. En el grupo B, un paciente (1,3 por ciento) falleció de causa no cardíaca y 2 (2,6 por ciento) precisaron revascularización por reestenosis. Las curvas de supervivencia libre de acontecimientos fueron significativamente diferentes en ambos grupos. La pertenencia al grupo A fue la única variable predictora de acontecimientos y, dentro de este grupo, la localización de la lesión en descendente anterior (DA) fue el principal factor predictor de la necesidad de revascularización. Conclusiones. La presencia de LNC en pacientes con síndrome coronario agudo y ACTP de la lesión causante predice una moderada tasa de revascularización a cortomedio plazo por inestabilización (AU)

[Transient ST Elevation: a finding that may be frequent in percutaneous atrial septal defect closure in adults]. / Elevación transitoria del segmento ST: una alteración que podría ser frecuente durante el cierre percutáneo de comunicaciones interauriculares en adultos.

Transient ST elevation in inferior leads has been described as a rare complication during percutaneous atrial septal defect closure. We present a series of adult patients who underwent percutaneous atrial septal defect closure with the Amplatzer device and in whom transient ST changes were observed frequently.

Elevación transitoria del segmento ST: una alteración que podría ser frecuente durante el cierre percutáneo de comunicaciones interauriculares en adultos / Transient ST elevation: a finding that may be frequent in percutaneous atrial septal defect closure in adults

La elevación transitoria del segmento ST en derivaciones inferiores ha sido descrita como rara complicación en el cierre percutáneo de comunicaciones interauriculares. Presentamos una serie de casos de cierre de comunicaciones interauriculares con el dispositivo Amplatzer en adultos en los que se observó dicha alteración de forma frecuente. (AU)

Angina inestable en el paciente octogenario: ¿es factible y eficaz el abordaje invasivo? / Unstable Angina in Octogenarians: Is an Invasive Approach Feasible and Effective?

Introducción y objetivos. La angina inestable comporta mayor riesgo en pacientes octogenarios, a pesar de lo cual éstos son manejados de forma más conservadora. Las técnicas de revascularización se han asociado a una mayor tasa de complicaciones en estos pacientes, pero los avances logrados permiten, hoy día, obtener mejores resultados. El objetivo de este trabajo ha sido evaluar el abordaje invasivo en pacientes octogenarios con angina inestable de alto riesgo o inadecuada respuesta al tratamiento médico. Pacientes y método. De enero de 1996 a octubre de 1999, 100 pacientes octogenarios con angina inestable fueron remitidos a nuestra unidad, de los cuales 74 (74 por ciento) fueron sometidos a angioplastia. Se evaluaron los resultados inmediatos, las complicaciones hospitalarias y el seguimiento clínico posterior. Resultados. Se trataron 145 lesiones en los 74 pacientes. El éxito del procedimiento fue del 92 por ciento. En el hospital se produjeron dos fallecimientos, ambos de causa cardíaca, y un infarto sin onda Q. Durante un seguimiento de 24 ñ 12 meses (4-50 meses) se registraron 14 fallecimientos (19,4 por ciento). Se efectuó una nueva revascularización en 10 pacientes (13,5 por ciento), nueve con angioplastia y uno con cirugía. La supervivencia libre de muerte e infarto al año fue del 89,2 por ciento. Al final del seguimiento permanecen vivos 58 pacientes (78,4 por ciento), 45 asintomáticos y 13 con angina estable clase I o II. Conclusiones. Los resultados fueron buenos, con un 92 por ciento de éxito en el procedimiento, un 96 por ciento de pacientes libres de muerte-infarto en la hospitalización y, tras 2 años de seguimiento, un 78,4 por ciento de pacientes vivos, la mayoría de ellos asintomáticos (AU)