Ultrassonografia intravascular para guiar a intervenção coronária percutânea: resultados do registro nacional português / Intravascular ultrasound in percutaneous coronary intervention guidance: results from Portuguese registry

Introdução: As diretrizes atuais recomendam o uso da ultrassonografia intravascular de coronárias como ferramenta adjuvante em situações difíceis. Objetivo: Caracterizar a utilização da ultrassonografia intravascular em Portugal e comparar os desfechos após intervenção coronária percutânea no tronco da coronária esquerda, guiada ou não por ultrassonografia intravascular. Métodos: Estudo observacional retrospectivo multicêntrico, que analisou pacientes submetidos à intervenção coronária percutânea entre janeiro de 2012 e dezembro de 2018, incluídos no Portuguese Registry on Interventional Cardiology da Sociedade Portuguesa de Cardiologia. Valor de p bicaudal <0,05 foi considerado estatisticamente significativo. Resultados: Este estudo demonstrou variação significativa na utilização da ultrassonografia intravascular em Portugal (valor de p qui-quadrado para tendência <0,001). O ano com maior utilização foi 2016 (2,4%). Houve aumento progressivo, nos últimos 7 anos, na utilização da ultrassonografia intravascular na intervenção coronária percutânea do tronco da coronária esquerda (valor de p qui-quadrado para tendência <0,001), com importantes diferenças regionais. A população submetida à intervenção coronária percutânea do tronco da coronária esquerda guiada por ultrassonografia intravascular era mais jovem, mas tinha maior prevalência de fatores de risco cardiovascular, disfunção sistólica ventricular e lesões coronárias complexas. Além disso, esse grupo de pacientes teve menor prevalência do desfecho primário intra-hospitalar (1,4% versus 3,9%; p=0,024). Porém, após análise multivariada ajustada para fatores de confusão, este estudo não demonstrou impacto significativo da utilização da ultrassonografia intravascular no desfecho intra-hospitalar. Conclusão: A utilização da ultrassonografia intravascular na intervenção coronária percutânea do tronco da coronária esquerda vem aumentando lentamente nos últimos 7 anos em Portugal. Neste estudo, a utilização desse método não teve impacto estatístico nos desfechos intra-hospitalares.

Background: Current guidelines recommend the use of coronary intravascular ultrasound as an adjunctive tool in challenging situations. Objective: To characterize the use of intravascular ultrasound in Portugal and compare outcomes after left main percutaneous coronary intervention, with or without intravascular ultrasound. Methods: A retrospective multicentric observational study analyzed patients who underwent percutaneous coronary intervention between January 2012 and December 2018 and were included in the Portuguese Registry on Interventional Cardiology of the Sociedade Portuguesa de Cardiologia. A two-sided p-value<0.05 was considered statistically significant. Results: This study revealed significant variation of intravascular ultrasound usage in Portugal over time (p-value Chi-squared for trend <0.001). The year with maximum use was 2016 (2.4%). Regarding left main percutaneous coronary intervention, there was a progressive increase in use of intravascular ultrasound (p-value Chi-squared for trend<0.001) in the last 7 years, with important regional differences. The population submitted to left main percutaneous coronary intervention with intravascular ultrasound was younger, but had a higher prevalence of some cardiovascular risk factors, ventricular systolic dysfunction, and complex coronary lesions. Moreover, this group of patients had lower prevalence of intrahospital primary endpoint (1.4% versus 3.9%; p=0.024). However, after multivariate analysis adjusted to confounding factors, this study did not demonstrate a significant impact of intravascular ultrasound on intrahospital endpoint. Conclusion: The overall use of intravascular ultrasound in left main percutaneous coronary intervention has been slowly increasing in the last seven years, in Portugal. In this study, the use of this method had no statistical impact in intrahospital endpoints.

Present and future economic impact of transcatheter aortic valve replacement on the Portuguese national healthcare system.

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has changed the treatment paradigm of severe aortic stenosis (AS). Nevertheless, in Portugal the penetration rate of TAVR is still very low and there is a paucity of data regarding its economic impact on the Portuguese healthcare system. AIMS: To perform an economic analysis of the present and future impact of TAVR in Portugal and to propose health policy recommendations for a new reimbursement model. METHODS: Hospital data from a high-volume center were used as a sample to calculate the costs of TAVR in Portugal. Information regarding the national penetration rate was derived from the EAPCI Valve for Life initiative. To estimate the future demand for TAVR, three scenarios (S) were constructed: S1, TAVR penetration according to current guidelines; S2, including intermediate-risk patients; and S3, including low-risk patients aged over 75 years. RESULTS: The total cost of each TAVR procedure in Portugal was 22 134.50 euros for the self-expanding valve (SEV) and 23 321.50 euros for the balloon-expanding valves (BEV). Most of the cost was driven by the price of the valve (SEV 74.5% vs. BEV 81.5%). The current national economic impact is estimated at 12 500 000 euros per year. In S1, the expected penetration rate would be 189 procedures per million population; in S2 we estimated an increase of 28% to 241 procedures per million population and in S3 an increase of 107% to 391 procedures per million population. The total economic impact would increase to 43 770 586 euros in S1 and to 90 754 310 euros in S3. CONCLUSIONS: TAVR is associated with a significant present and future economic impact on the Portuguese healthcare system. A new model of reimbursement in Portugal should be discussed and implemented.

Thrombus aspiration in patients with ST-elevation myocardial infarction: results of a national registry of interventional cardiology.

BACKGROUND: We aimed to evaluate the impact of thrombus aspiration (TA) during primary percutaneous coronary intervention (P-PCI) in 'real-world' settings. METHODS: We performed a retrospective study, using data from the National Registry of Interventional Cardiology (RNCI 2006-2012, Portugal) with ST-elevation myocardial infarction (STEMI) patients treated with P-PCI. The primary outcome, in-hospital mortality, was analysed through adjusted odds ratio (aOR) and 95% confidence intervals (95%CI). RESULTS: We assessed data for 9458 STEMI patients that undergone P-PCI (35% treated with TA). The risk of in-hospital mortality with TA (aOR 0.93, 95%CI:0.54-1.60) was not significantly decreased. After matching patients through the propensity score, TA reduced significantly the risk of in-hospital mortality (OR 0.58, 95%CI:0.35-0.98; 3500 patients). CONCLUSIONS: The whole cohort data does not support the routine use of TA in P-PCI, but the results of the propensity-score matched cohort suggests that the use of selective TA may improve the short-term risks of STEMI.

Port-A-Cath Catheter Embolization to Distal Pulmonary Artery Branches: Two Tailored Percutaneous Retrieval Approaches.

Several types of intravascular devices and catheters are frequently used for long-term drug therapy, especially for oncological patients. As a result, complications are becoming increasingly common, namely catheter embolization. Retrieving these devices is important, as embolized fragments may lead to serious consequences, such as arrhythmias, myocardial injury, thrombosis, infection, and even perforation and death. We describe 2 cases of long-term drug catheter (Port-A-Cath) fracture, incidentally documented in a routine chest radiograph. In both cases, percutaneous extraction was attempted, yet the procedure was complicated by embolization of smaller fragments into the arterial pulmonary vasculature. We describe unusual approaches in successfully retrieving the remaining fragments. The ideal approaches for removal of foreign bodies from the cardiovascular system differ from case to case, but percutaneous extraction should be preferred in most of the cases. Less common techniques may be helpful in challenging cases.

Migración retrógrada subaguda de TAVI solucionada con un procedimiento valve-in-valve / Subacute retrograde TAVI migration successfully treated with a valve-in-valve procedure

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Renal denervation for resistant hypertension.

There is a marked contrast between the high prevalence of hypertension and the low rates of adequate control. A subset of patients with suboptimal blood pressure control have drug-resistant hypertension, in the pathophysiology of which chronic sympathetic hyperactivation is significantly involved. Sympathetic renal denervation has recently emerged as a device-based treatment for resistant hypertension. In this review, the pathophysiological mechanisms linking the sympathetic nervous system and cardiovascular disease are reviewed, focusing on resistant hypertension and the role of sympathetic renal denervation. An update on experimental and clinical results is provided, along with potential future indications for this device-based technique in other cardiovascular diseases.

Hybrid closure of postinfarction ventricular septal rupture enlargement after transcathether closure with Amplatzer occluder.

Ventricular septal rupture (VSR) is nowadays a rare complication of myocardial infarction (MI), but with a mortality rate still very high. Urgent surgical correction is recommended, although in specific cases percutaneous closure of a post-infarct VSR is a therapeutic option or a bridge to surgical correction. We report a case of an 80-year-old woman, with a subacute anterior MI with an antero-septal VSR. Rapid clinical deterioration in a high-surgical-risk patient led us to attempt percutaneous VSR closure at day 8 post MI. A 16-mm Amplatzer post-infarction (PI) muscular VSD closed the defect with intra-cardiac echocardiography guidance, that allowed conscious sedation. Clinical and haemodynamic improvement was immediate. Unfortunately, a small orifice distal to the device persisted, which enlarged to 8 mm over the following days, with a Qp/Qs shunt of 1.9. At day 17 post MI, the VSR was surgically closed by suturing the Amplatzer device to the septum. A residual shunt was evident, but with no progression, being the patient discharged in NYHA class I. Percutaneous closure of a post-MI VSR as a bridge to surgery is a therapeutic option in patients with high surgical risk, allowing haemodynamic stabilization and thus gaining time for a further surgical intervention if needed, improving these patients grim prognosis. Intra-cardiac echocardiography for monitoring the percutaneous procedure instead of a transoesophageal approach, as well as the surgical technique, make this case unique.

Role of abciximab in the treatment of coronary artery disease.

Glycoprotein IIb/IIIa complex is a crucial membrane receptor for platelet aggregation, binding platelets to fibrinogen and establishing interplatelet bridges. This receptor is the common end point of the multiple activation pathways of a platelet. Antiplatelet agents, such as aspirin or thienopyridines, including ticlopidine and clopidogrel, inhibit one or more but not all, of these pathways. Inhibitors of the receptor are powerful platelet antiaggregants and include two groups of agents: non-competitive receptor blockers, such as abciximab, and competitive antagonists, such as tirofiban and eptifibatide. Abciximab is a monoclonal antibody that binds to the glycoprotein IIb/IIIa complex, thus blocking the interaction with fibrinogen. It is used for treatment of coronary artery disease, being well-studied in the setting of acute coronary syndromes and percutaneous coronary intervention, in which a rapid and effective antiaggregation is clinically important.