Comparing Balloon Dilation to Non-Balloon Dilation for Access in Ultrasound-Guided Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis.

PURPOSE: This study aims to evaluate the safety and efficacy of ultrasound-guided balloon dilation compared to non-balloon dilation for percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A systematic review and meta-analysis were conducted by searching PubMed, EMBASE, and the Cochrane Library. Results were filtered using predefined inclusion and exclusion criteria as described and meta-analysis was performed using Review Manager 5.4 software. RESULTS: A total of six studies involving 1189 patients who underwent PCNL were included. The meta-analysis results demonstrated that compared to non-balloon dilation, balloon dilation was associated with reduced haemoglobin drop [mean difference (MD) = -0.26, 95% CI = -0.40 ~ -0.12, P = 0.0002], decreased transfusion rate [odds ratio (OR) = 0.47, 95% CI = 0.24 ~ 0.92, P = 0.03], shorter tract establishment time (MD = -1.30, 95% CI = -1.87 ~ -0.72, P < 0.0001) and shorter operation time (MD = -5.23, 95% CI = -10.19 ~ -0.27, P = 0.04). CONCLUSIONS: Overall, ultrasound-guided balloon dilatation offered several advantages in PCNL procedures. It facilitated faster access establishment, as evidenced by shorter access creation time. Additionally, it reduced the risk of kidney injury by minimizing postoperative haemoglobin drop and decreasing the need for transfusions. Moreover, it enhanced the efficiency of surgery by reducing the operation time. However, it is important to note that the quality of some included studies was subpar, as they did not adequately control for confounding factors that may affect the outcomes. Therefore, further research is necessary to validate and strengthen these findings.

Comparing Balloon Dilation to Non-Balloon Dilation for Access in Ultrasound-Guided Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

ABSTRACT Purpose: This study aims to evaluate the safety and efficacy of ultrasound-guided balloon dilation compared to non-balloon dilation for percutaneous nephrolithotomy (PCNL). Materials and methods: A systematic review and meta-analysis were conducted by searching PubMed, EMBASE, and the Cochrane Library. Results were filtered using predefined inclusion and exclusion criteria as described and meta-analysis was performed using Review Manager 5.4 software. Results: A total of six studies involving 1189 patients who underwent PCNL were included. The meta-analysis results demonstrated that compared to non-balloon dilation, balloon dilation was associated with reduced haemoglobin drop [mean difference (MD) = -0.26, 95% CI = -0.40 ~ -0.12, P = 0.0002], decreased transfusion rate [odds ratio (OR) = 0.47, 95% CI = 0.24 ~ 0.92, P = 0.03], shorter tract establishment time (MD = -1.30, 95% CI = -1.87 ~ -0.72, P < 0.0001) and shorter operation time (MD = -5.23, 95% CI = -10.19 ~ -0.27, P = 0.04). Conclusions: Overall, ultrasound-guided balloon dilatation offered several advantages in PCNL procedures. It facilitated faster access establishment, as evidenced by shorter access creation time. Additionally, it reduced the risk of kidney injury by minimizing postoperative haemoglobin drop and decreasing the need for transfusions. Moreover, it enhanced the efficiency of surgery by reducing the operation time. However, it is important to note that the quality of some included studies was subpar, as they did not adequately control for confounding factors that may affect the outcomes. Therefore, further research is necessary to validate and strengthen these findings.

Safety and efficacy of arteriovenous fistula angioplasties performed by nephrologists: report from a Brazilian interventional nephrology center / Segurança e eficácia de angioplastias de fístulas arteriovenosas realizadas por nefrologistas: relato de um centro de nefrologia intervencionista brasileiro

ABSTRACT Introduction: Arteriovenous fistulas (AVF) are the first choice vascular access for hemodialysis. However, they present a high incidence of venous stenosis leading to thrombosis. Although training in interventional nephrology may improve accessibility for treatment of venous stenosis, there is limited data on the safety and efficacy of this approach performed by trained nephrologists in low-income and developing countries. Methods: This study presents the retrospective results of AVF angioplasties performed by trained nephrologists in a Brazilian outpatient interventional nephrology center. The primary outcome was technical success rate (completion of the procedure with angioplasty of all stenoses) and secondary outcomes were complication rates and overall AVF patency. Findings: Two hundred fifty-six angioplasties were performed in 160 AVF. The technical success rate was 88.77% and the main cause of technical failure was venous occlusion (10%). The incidence of complications was 13.67%, with only one patient needing hospitalization and four accesses lost due to the presence of hematomas and/or thrombosis. Grade 1 hematomas were the most frequent complication (8.2%). The overall patency found was 88.2 and 80.9% at 180 and 360 days after the procedure, respectively. Conclusion: Our findings suggest that AVF angioplasty performed by trained nephrologists has acceptable success rates and patency, with a low incidence of major complications as well as a low need for hospitalization.

RESUMO Introdução: As fístulas arteriovenosas (FAV) são a primeira escolha de acesso vascular para hemodiálise. No entanto, elas apresentam uma alta incidência de estenoses venosas levando à trombose. Embora o treinamento em nefrologia intervencionista possa melhorar a acessibilidade para o tratamento das estenoses venosas, há dados limitados sobre a segurança e a eficácia desta abordagem realizada por nefrologistas treinados em países em desenvolvimento e de baixa renda. Métodos: Este estudo apresenta os resultados retrospectivos de angioplastias de FAV realizadas por nefrologistas treinados em um centro ambulatorial brasileiro de nefrologia intervencionista. O desfecho primário foi a taxa de sucesso técnico (conclusão do procedimento com angioplastia de todas as estenoses) e os desfechos secundários foram taxas de complicação e a patência geral das FAV. Achados: Duzentas e cinquenta e seis angioplastias foram realizadas em 160 FAV. A taxa de sucesso técnico foi de 88,77% e a principal causa de falha técnica foi a oclusão venosa (10%). A incidência de complicações foi de 13,67%, com apenas um paciente necessitando de internação e quatro acessos perdidos devido à presença de hematomas e/ou trombose. Hematomas de grau 1 foram a complicação mais frequente (8,2%). A patência geral encontrada foi de 88,2 e 80,9% a 180 e 360 dias após o procedimento, respectivamente. Conclusão: Nossos achados sugerem que a angioplastia de FAV realizada por nefrologistas treinados tem taxas de sucesso e patência aceitáveis, com uma baixa incidência de complicações maiores, bem como uma baixa necessidade de hospitalização.

Acute Myocardial Infarction and Percutaneous Coronary Intervention: What does the Epidemiological Data of the Last Years Indicate?

Abstract Background: ST-segment elevation acute myocardial infarction (STEMI) is a pathological process that involves cardiac muscle tissue death. Intravenous thrombolysis with fibrinolytics or primary percutaneous coronary intervention (PCI), an invasive technique, can be performed for tissue revascularization. PCI has been preferred as compared to non-invasive methods, although few studies have described its use in Brazil. Objectives: The aim of the present study was to analyze data on the use of primary PCI and investigate the relevance of hospitalizations for the treatment of STEMI in the country. Methods: A descriptive, cross-sectional analysis of data from the Brazilian Unified Health system (SUS) Department of Informatics (DATASUS) from 2010 to 2019 was conducted. Results: Hospitalizations for STEMI represented 0.6% of all hospital admissions in Brazil in the analyzed period, 0.9% of hospital costs, and 2.1% of deaths. The number of hospitalizations due to STEMI was 659,811, and 82,793 for PCIs. Length of hospital stay was 36.0% shorter and mortality rate was 53.3% lower in PCI. The mean cost of PCI was 3.5-fold higher than for treatment of STEMI. Conclusions: Data on hospitalizations for STEMI treatment in Brazil revealed high hospitalization and mortality rates, elevated costs, and long hospital stay. Although primary PCI is a more expensive and less used technique than other methods, it can reduce the length of hospital stay and mortality in the treatment of STEMI.

Síndrome de Wellens: o infarto agudo do miocárdio iminente / Wellens Syndrome: impending acute myocardial infarction

A síndrome de Wellens foi descrita em 1982 por Zwaan, Bär e Wellens. No eletrocardiograma, observam-se alterações morfológicas da onda T nas derivações precordiais, sugerindo estenose proximal grave da artéria coronária descendente anterior que representa iminente risco de infarto agudo do miocárdio e/ou morte súbita, com discreta ou nenhuma alteração da troponina sérica. Seu reconhecimento antecipado e a abordagem com reperfusão miocárdica precoce evitam desfechos desfavoráveis. A intervenção coronária percutânea e a revascularização miocárdica cirúrgica são as estratégias mais utilizadas para tratamento. Os autores descrevem dois casos de síndrome de Wellens tipos A e B tratados por diferentes estratégias de reperfusão.

Wellens syndrome was described by Zwaan, Bär and Wellens, in 1982. On the electrocardiogram, T wave morphological alterations are observed in precordial leads, suggesting severe proximal stenosis of the left anterior descending coronary artery and an imminent risk of acute myocardial infarction and/or sudden death, with slight or no alteration in serum troponin. Its early recognition and management with early myocardial reperfusion avoid unfavorable outcomes. Percutaneous coronary intervention and surgical myocardial revascularization are the most used strategies for treatment. The authors describe two cases of types A and B Wellens syndrome treated with different reperfusion strategies.

Perfil Aterosclerótico da Artéria Carótida como Preditor de Risco para Reestenose após Implante de Stent Coronário / Carotid Artery Atherosclerotic Profile as Risk Predictor for Restenosis After Coronary Stenting

Resumo Fundamento: A incidência de reestenose da artéria coronária após o implante de um stent não farmacológico é mais baixa que na angioplastia com balão; no entanto, ainda apresenta altas taxas. Objetivo: O objetivo deste estudo foi identificar novos indicadores de risco para reestenose de stent usando ultrassonografia das carótidas que, em conjunto com indicadores já existentes, ajudariam na escolha do stent. Métodos: Realizamos um estudo prospectivo transversal incluindo 121 pacientes consecutivos com doença arterial coronariana que foram submetidos à intervenção coronária percutânea com angiografia nos 12 meses anteriores. Após os casos de reestenose de stent serem identificados, os pacientes foram submetidos à ultrassonografia de carótidas para avaliar a espessura da camada íntima média e placas ateroscleróticas. Os dados foram analisados por regressão múltipla de Cox. O nível de significância foi p<0,05. Resultados: A idade mediana dos pacientes foi de 60 anos (1º quartil = 55, 3º quartil = 68), e 64,5% dos pacientes eram do sexo masculino. A angiografia coronária mostrou que 57 pacientes (47,1%) apresentaram reestenose de stent. Cinquenta e cinco pacientes (45,5%) apresentaram placas ateroscleróticas ecolucentes nas artérias carótidas e 54,5% apresentaram placas ecogênicas ou nenhuma placa. Dos pacientes que apresentaram placas ecolucentes, 90,9% apresentaram reestenose do stent coronário, e daqueles com placas ecogênicas ou nenhuma placa, 10,6% apresentaram reestenose de stent. A presença de placas ecolucentes nas artérias carótidas aumentou o risco de reestenose de stent coronário em 8,21 vezes (RR=8,21;IC95%: 3,58-18,82; p<0,001). Conclusões: A presença de placas ateroscleróticas ecolucentes na artéria carótida constitui um preditor de risco de reestenose de stent coronário e deve ser considerada na escolha do tipo de stenta ser usado na angioplastia coronária.

Abstract Background: The incidence of restenosis of the coronary artery after a bare-metal stent implant has been lower than in simple balloon angioplasty; however, it still shows relatively high rates. Objective: The aim of this study was to find new risk indicators for in-stent restenosis using carotid ultrasonography, that, in addition to the already existing indicators, would help in decision-making for stent selection. Methods: We carried out a cross-sectional prospective study including 121 consecutive patients with chronic coronary artery disease who had undergone percutaneous coronary intervention with repeat angiography in the previous 12 months. After all cases of in-stent restenosis were identified, patients underwent carotid ultrasonography to evaluate carotid intima-media thickness and atherosclerosis plaques. The data were analyzed by Cox multiple regression. The significance level was set a p<0.05. Results: Median age of patients was 60 years (1st quartile = 55, 3rd quartile = 68), and 64.5% of patients were male. Coronary angiography showed that 57 patients (47.1%) presented in-stent restenosis. Fifty-five patients (45.5%) had echolucent atherosclerotic plaques in carotid arteries and 54.5% had echogenic plaques or no plaques. Of patients with who had echolucent plaques, 90.9% presented coronary in-stent restenosis. Of those who had echogenic plaques or no plaques, 10.6% presented in-stent restenosis. The presence of echolucent plaques in carotid arteries increased the risk of coronary in-stent restenosis by 8.21 times (RR=8.21; 95%CI: 3.58-18.82; p<0.001). Conclusions: The presence of echolucent atherosclerotic plaques in carotid artery constitutes a risk predictor of coronary instent restenosis and should be considered in the selection of the type of stent to be used in coronary angioplasty.

Tempos de atendimento e desfechos no infarto agudo do miocárdio com supradesnivelamento ST / Time of care and outcomes in ST-segment elevation myocardial infarction

Objetivo: Comparar os tempos de tratamento dor-porta e porta-balão em indivíduos com infarto agudo do miocárdio com supradesnivelamento ST com os desfechos cardiovasculares em 30 dias. Métodos: Trata-se de uma coorte histórica, realizada por meio da pesquisa de prontuários eletrônicos e dos bancos de dados já existentes dos serviços de hemodinâmica de todos os indivíduos atendidos com diagnóstico de infarto agudo do miocárdio com supradesnivelamento ST e submetidos à angioplastia, no período de março de 2015 a setembro de 2016, em dois hospitais públicos de grande porte de Porto Alegre (RS). Os desfechos foram o óbito intra-hospitalar e em 30 dias e os eventos cardíacos maiores hospitalares e em 30 dias. Resultados: Foram avaliadas as informações de 808 indivíduos, sendo 26,9% provenientes do Hospital de Clínicas de Porto Alegre e 73,1% do Instituto de Cardiologia ­ Fundação Universitária de Cardiologia. Não houve diferença significativa na caracterização da amostra. Um terço dos indivíduos analisados apresentou tempo dor- -porta menor ou igual a 180 minutos, e 72% tiveram tempo porta-balão menor que 90 minutos. A mediana do tempo total de isquemia foi de 338 minutos. Na avaliação dos tempos não houve diferença significativa entre os dois hospitais. Para eventos cardíacos maiores e óbitos intra- -hospitalares, o único tempo que se mostrou significativo, após o ajuste multivariado, foi o porta-balão, em que os indivíduos com tempo maior que 90 minutos apresentaram razão de risco de 1,06 (IC95% 1,02-1,11) e 5,78 (IC95% 1,44-23,2), respectivamente, para eventos cardíacos maiores e óbitos intra-hospitalares. Para eventos cardíacos maiores total e óbito total, nenhum dos três tempos se associou significativamente com o desfecho após ajuste. Contudo, o tempo porta-balão maior ou igual a 90 minutos também foi significativo para razão de risco bruto para ambos, assim como a dor-porta para óbito total. Conclusão: Os dados da pesquisa corroboram as recomendações internacionais para cumprimento dos menores tempos de atendimento, em especial do tempo porta-balão, para o bom prognóstico. Infelizmente, no país, o tempo de isquemia miocárdica ainda está muito aquém do ótimo, necessitando de melhorias na área para melhorar os desfechos nesses indivíduos.

Objective: To compare symptom-onset-to-door and door- -to-balloon times in individuals with ST-segment elevation myocardial infarction to the 30-day cardiovascular outcomes. Methods: This is a historical cohort, using electronic medical records and the existing databases of hemodynamic services of all individuals diagnosed with ST-segment elevation myocardial infarction undergoing angioplasty between March 2015 and September 2016, in two large public hospitals in Porto Alegre. The outcomes were in-hospital death and death in 30 days, and major adverse cardiac events in hospital and in 30 days. Results: The information of 808 patients was evaluated, with 26.9% from Hospital de Clínicas de Porto Alegre, and 73.1% from the Instituto de Cardiologia ­ Fundação Universitária de Cardiologia. There was no significant difference in the characterization of the sample. One-third of the individuals evaluated presented symptom-onset-to-door of 180 minutes or less, and 72% had door-to- -balloon time below 90 minutes. The median total ischemic time was 338 minutes. In the evaluation of the times, there was no significant difference between the two hospitals. For more major cardiac events and intra-hospital deaths, the only time that proved to be significant after the multivariate adjustment was the door-to-balloon time, in which individuals with time higher than 90 minutes had a risk ratio of 1.06 (95% CI 1.02-1.11) for major cardiac events and 5.78 (95% CI 1.44-23.2), for intra-hospital deaths. For total major adverse cardiac events and total death, none of the 3 times was significantly associated with the outcome after adjustment; however, door-to-balloon of 90 minutes or more was also significant for crude risk ratio for both, as well as symptom-onset-to-door for total death. Conclusion: The research data corroborate the international recommendations to meet shorter service times, especially door-to-balloon time, for a good prognosis. Unfortunately, in the country, the time of myocardial ischemia is still far from optimal, requiring improvement in the area to improve the outcomes in these individuals.

Door-to-balloon Time in Cardiovascular Emergency Care in a Hospital of Northern Brazil

Abstract Background The use of an adequate door-to-balloon time (≤ 90 minutes) is crucial in improving the quality of care provided to patients with ST-segment elevation myocardial infarction (STEMI). Objective To determine the door-to-balloon time in the management of STEMI patients in a cardiovascular emergency department in a hospital of northern Brazil. Methods This was a cross-sectional study based on review of medical records. A total of 109 patients with STEMI admitted to the emergency department of a referral cardiology hospital in Pará State, Brazil, between May 2017 and December 2017. Correlations of the door-to-balloon time with length of hospital stay and mortality rate were assessed, as well as whether the time components of the door-to-balloon time affected the delay in performing primary percutaneous coronary intervention. Quantitative variables were analyzed by Spearman correlation and the G test was used for categorical variables. A p<0.05 was set as statistically significant. Results Median door-to-balloon time was 104 minutes. No significant correlation was found between door-to-balloon time and length of hospital stay or deaths, but significant correlations were found between door-to-balloon time and door-to-ECG time (p<0.001) and ECG-to-activation (of an interventional cardiologist) time (p<0.001). Conclusion The door-to-balloon time was longer the recommended and was not correlated with the length of hospital stay or in-hospital mortality. Door-to-ECG time and ECG-to-activation time contributed to the delay in performing the primary percutaneous coronary intervention. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

SCA con elevación del ST: impacto del tiempo al diagnóstico en el tiempo puerta-balón en el mundo real. Datos del registro ARGEN-IAM-ST / ST-Segment Elevation ACS: Impact of Time to Diagnosis on Door-To-Balloon Time in the Real World. Data from the ARGEN-IAM-ST Registry

RESUMEN • Introducción: El tiempo trascurrido desde el inicio de los síntomas de infarto hasta el diagnóstico (TAD) puede influir en lograr un tiempo puerta-balón (TPB) <90 min. Material y métodos: Análisis retrospectivo que incluyó 1518 pacientes ingresados en forma prospectiva y consecutiva al registro ARGEN-IAM-ST. El 37,8% de ellos fue tratado con un TPB <90 min y el TAD (mediana) fue de 120 min (RIC 60-266). Se dividió a la población de acuerdo al TAD en dos grupos: menor de 120 min y mayor o igual que 120 min. Un TPB <90 min se logró más frecuentemente en el primer grupo (TAD <120 min): 44%, vs. 32,2% en el segundo grupo (p <0,001). Resutados: En el 56% de los pacientes con ATC in situ y TAD <120 min se logró un TPB <90 min, vs. en el 37,1% de quienes tuvieron un TAD >120 min (p <0,001). En pacientes derivados, no hubo diferencias en TPB <90 min de acuerdo al TAD: 27,5% vs. 25,7 (p: 0,3). En pacientes ingresados en horario laborable, el TPB <90 min se logró con TAD <120 min en un 49,8% vs. 36,3% con TAD >120 min (p: 0,003); la frecuencia siguió un patrón similar en los pacientes ingresados en horarios no laborables: 41,9% vs. 30,4%, respectivamente (p <0,001). Los predictores independientes de lograr un TPB <90 min en el análisis multivariado fueron la edad <75 años: OR 1,57 (1,1-2,25; p: 0,01), ATC en horario laborable: OR 1,32 (1,04-1,67; p: 0,002), ATC in situ: OR 2,4 (1,9-3,0; p <0,001), tener un ECG prehospitalario: OR 2,22 (1,73-2,86; p <0,001) y un TAD <120 min: OR 1,53 (1,23-1,9; p <0,001). Conclusiones: En los pacientes con un TAD <120 minutos se logra más frecuentemente un TPB <90 min, especialmente en los tratados in situ y en horario laborable. En los pacientes derivados, solo 1 de cada 3 logra un TPB <90 min y no hay relación con el TAD.

ABSTRACT • Background: Time elapsed from the onset of symptoms to diagnosis (TTD) can influence in achieving a door-to-balloon time <90 min (DBT <90 min). Methods: A retrospective analysis was performed on 1,518 patients prospectively and consecutively included in the ARGEN-AMI-ST registry. In 37.8% of cases. patients were treated with DBT <90 min and a median TTD of 120 min (IQR 60-266). The population was divided according to TTD above or below 120 min. A DBT <90 min was achieved more frequently in those with TTD <120 min: 44% vs. 32.2% (p <0.001) respectively. Results: In patients with in situ percutaneous coronary intervention (PCI) and TTD <120 min, DBT <90 min was achieved in 56% vs. 37.1% of cases with TTD >120 min (p <0.001). In referred patients, there were no differences in DBT <90 min according to TTD: 27.5% vs. 25.7% (p: 0.3). In patients admitted during working hours, DBT <90 min was achieved with TTD <120 min in 49.8% vs. 36.3% with TTD >120 min (p: 0.003), as well as in patients admitted during non-working hours: 41.9% vs. 30.4% (p <0.001). The independent predictors of achieving a DBT <90 min in the multivariate analysis were age <75 years: OR 1.57 (1.1-2.25; p: 0.01), PCI during working hours: OR 1.32 (1.04-1.67; p: 0.002), PCI in situ: OR 2.4 (1.9-3.0; p <0.001), having a pre-hospital ECG: OR 2.22 (1.73-2.86; p <0.001) and a TTD <120 min: OR 1.53 (1.23-1.9; p <0.001). Conclusions: In patients with TTD <120 minutes, a DBT <90 minutes is more frequently achieved, especially in those treated in situ and during working hours. In referred patients, only 1 in 3 achieves a DBT<90 min and there is no relationship with TTD.

Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty / Análise Comparativa entre Pacientes com IAMCSST Transferidos e Pacientes de Demanda Espontânea Submetidos à Angioplastia Primária

Abstract Background: Studies have shown the benefits of rapid reperfusion therapy in acute myocardial infarction. However, there are still delays during transport of patients to primary angioplasty. Objective: To evaluate whether there is a difference in total ischemic time between patients transferred from other hospitals compared to self-referred patients in our institution. Methods: Historical cohort study including patients with acute myocardial infarction treated between April 2014 and September 2015. Patients were divided into transferred patients (group A) and self-referred patients (group B). Clinical characteristics of the patients were obtained from our electronic database and the transfer time was estimated based on the time the e-mail requesting patient's transference was received by the emergency department. Results: The sample included 621 patients, 215 in group A and 406 in group B. Population characteristics were similar in both groups. Time from symptom onset to arrival at the emergency department was significantly longer in group A (385 minutes vs. 307 minutes for group B, p < 0.001) with a transfer delay of 147 minutes. There was a significant relationship between the travel distance and increased transport time (R = 0.55, p < 0.001). However, no difference in mortality was found between the groups. Conclusion: In patients transferred from other cities for treatment of infarction, transfer time was longer than that recommended, especially in longer travel distances.

Resumo Fundamento: Estudos mostram o benefício da terapia de reperfusão rápida no infarto agudo do miocárdio. No entanto, ainda ocorrem atrasos durante o transporte de pacientes para angioplastia primária. Objetivo: Definir se existe uma diferença no tempo total de isquemia entre pacientes transferidos de outro hospital comparados aos que procuram o serviço espontaneamente. Método: Estudo de coorte histórico, incluindo pacientes atendidos com infarto entre abril de 2014 e setembro de 2015. Os pacientes foram divididos em pacientes transferidos (grupo A) e por demanda espontânea (grupo B). As características clínicas dos pacientes foram retiradas do banco de dados de infarto e o tempo de transferência foi estimado tendo como base o correio eletrônico de acordo com o horário de contato. O nível de significância adotado foi um p < 0,05%. Resultados: A amostra incluiu 621 pacientes, 215 no grupo A e 406 no grupo B. As características populacionais foram semelhantes nos dois grupos. O delta T foi significativamente maior no grupo de pacientes transferidos (385 minutos vs. 307 minutos para o grupo B, p < 0,001) com um atraso decorrente do transporte de 147 minutos. Houve relação significativa da distância de transferência e aumento do tempo de transporte (R = 0,55; p < 0,001). Entretanto, não houve diferença na mortalidade entre os grupos. Conclusão: Pacientes transferidos de outras cidades para tratamento de infarto tem Delta T de transferência acima do recomendado, com tempo ainda mais longo quanto maior a distância a ser percorrida.

Balloon dilation for failed pyeloplasty in children?

OBJECTIVE: Pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). However, the failure rate of pyeloplasty is as high as 10% and repeat pyeloplasty is more difficult. This study aimed to evaluate the efficacy of balloon dilatation for failed pyeloplasty in children. MATERIALS AND METHODS: Between 2011 and 2017, 15 patients, aged 6 months to 14 years, were treated with balloon dilation for restenosis of UPJO after a failed pyeloplasty. Ultrasound and intravenous urography were used to evaluate the primary outcome. Success was defined as the relief of symptoms and improvement of hydronephrosis, which was identified by ultrasound at the last follow-up. RESULTS: All patients successfully completed the operation, 13 patients by retrograde approach and 2 patients by antegrade approach. Thirteen patients were followed for a median of 15 (4 to 57) months and 2 patients were lost to follow-up. Resolution of the hydronephrosis was observed in 5 cases. The anteroposterior diameter (APD) of the pelvis decreased by an average of 12.4 ± 14.4mm. Eight patients needed another surgery. The average postoperative hospital stay was 1.78 ± 1.4 days. Two patients experienced fever after balloon dilation. No other complications were found. CONCLUSIONS: Balloon dilatation surgery is safe for children, but it is not recommended for failed pyeloplasty in that group of patients, owing to the low success rate.

Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient / Impacto Clínico e Custo-Efetividade da FFR em Comparação à Angiografia em Pacientes com Doenças Multiarteriais Submetidos à ICP

Abstract Background: In multivessel disease patients with moderate stenosis, fractional flow reserve (FFR) allows the analysis of the lesions and guides treatment, and could contribute to the cost-effectiveness (CE) of non-pharmacological stents (NPS). Objectives: To evaluate CE and clinical impact of FFR-guided versus angiography-guided angioplasty (ANGIO) in multivessel patients using NPS. Methods: Multivessel disease patients were prospectively randomized to FFR or ANGIO groups during a 5 year-period and followed for < 12 months. Outcomes measures were major adverse cardiac events (MACE), restenosis and CE. Results: We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34 (49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or acute coronary syndrome. In FFR, there were 26 patients with biarterial disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24 (68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve MACEs were observed - 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9 (13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%) in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%) lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05 ± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO and FFR, respectively. The difference of effectiveness was of 1.82%. Conclusion: FFR reduced the number of lesions treated and stents, and the need for target-lesion revascularization, with a CE comparable with that of angiography.

Resumo Fundamentos: Em pacientes multiarteriais e lesões moderadas, a reserva de fluxo fracionada (FFR) avalia cada lesão e direciona o tratamento, podendo ser útil no custo-efetividade (CE) de implante de stents não farmacológicos (SNF). Objetivos: Avaliar CE e impacto clínico da angioplastia + FFR versus angioplastia + angiografia (ANGIO), em multiarteriais, utilizando SNF. Métodos: pacientes com doença multiarteriais foram randomizados prospectivamente durante ±5 anos para FFR ou ANGIO, e acompanhados por até 12 meses. Foram avaliados eventos cardíacos maiores (ECAM), reestenose e CE. Resultados: foram incluídos 69 pacientes, 47(68,1%) homens, 34(49,2%) no FFR e 35(50,7%) no ANGIO, idade 62,0 ± 9,0 anos, com angina estável e Síndrome Coronariana Aguda estabilizada. No FFR, havia 26 com doença (76,5%) biarterial e 8 (23,5%) triarterial, e no grupo ANGIO, 24(68,6%) biarteriais e 11(31,4%) triarteriais. Ocorreram 12(17,3%) ECAM - 3(4,3%) óbitos: 2(5,8%) no FFR e 1(2,8%) no ANGIO, 9(13,0%) anginas, 4(11,7%) no FFR e 5(14,2%) no ANGIO, 6 reestenoses: 2(5,8%) no FFR e 4 (11,4%) no ANGIO. Angiografia detectou 87(53,0%) lesões no FFR, 39(23,7%) com ICP e 48(29,3%) com tratamento clínico; e 77(47,0%) lesões no ANGIO, todas submetidas à angioplastia. Quanto aos stents, registrou-se 39(33,3%) (0,45 ± 0,50 stents/lesão) no FFR e 78(66,6%) (1,05 ± 0,22 stents/lesão) no ANGIO (p = 0,0001); ANGIO utilizou 51,4% a mais que o FFR. Análise de CE revelou um custo de R$5045,97 e R$5.430,60 nos grupos ANGIO e FFR, respectivamente. A diferença de efetividade foi 1,82%. Conclusões: FFR diminuiu o número de lesões tratadas e de stents e necessidade de revascularização do vaso-alvo, com CE comparável ao da angiografia.

Impact of myocardial revascularization method on smoking cessation: coronary artery bypass grafting versus percutaneous coronary intervention

Abstract Introduction: Smoking is a serious public health issue, being a precursor of heart disease and a predictor of sudden death due to myocardial ischemia. Major events in the patient's health can lead to radical changes in habits and the choice for different myocardial revascularization methods might differently impact smoking cessation and relapse. Objective: To study the rate and perpetuation of smoking cessation after myocardial revascularization comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Methods: Smokers submitted to myocardial revascularization were divided into CABG and PCI groups. The research was conducted through interviews at the Hospital Santa Lucinda outpatient clinic. Patients with smoking cessation longer than 90 days before hospital admission, combined procedures, hospital readmission before 360 days after discharge, cases of death at any time, and emergency procedures were excluded from the study. The start of the smoking cessation period was determined as just after hospital discharge, with a follow-up of 12 months. Results: The proportion of patients reporting smoking relapse was significantly lower in the CABG than in the PCI group at 30 (11.1% vs. 20.8%; P=0.039) and at 180 days (23.1% vs. 41.5%; P=0.002), but no differences were observed between the two groups at 360 days after hospital discharge (51.9% vs. 54.1%; P=0.719). High levels of nicotine dependence and passive smoking showed to be important predictors of smoking relapse in the long-term. Conclusion: The occurrence of a major surgical procedure seems to have beneficial psychological effects, representing an interesting setting for smoking cessation counseling to have higher chances of success.