Clinical practice guideline for transcatheter versus surgical valve replacement in patients with severe aortic stenosis in Latin America

In elderly (75 years or older) patients living in Latin America with severe symptomatic aortic stenosis candidates for transfemoral approach, the panel suggests the use of transcatheter aortic valve implant (TAVI) over surgical aortic valve replacement (SAVR). This is a conditional recommendation, based on moderate certainty in the evidence. This recommendation does not apply to patients in which there is a standard of care, like TAVI for patients at very high risk for cardiac surgery or inoperable patients, or SAVR for non-elderly patients (eg, under 65 years old) at low risk for cardiac surgery. The suggested age threshold of 75 years old is based on judgement of limited available literature and should be used as a guide rather than a determinant threshold. The conditional nature of this recommendation means that the majority of patients in this situation would want a transfemoral TAVI over SAVR, but some may prefer SAVR. For clinicians, this means that they must be familiar with the evidence supporting this recommendation and help each patient to arrive at a management decision integrating a multidisciplinary team discussion (Heart Team), patient's values and preferences through shared decision-making, and available resources. Policymakers will require substantial debate and the involvement of various stakeholders to implement this recommendation.

Clinical practice guideline for transcatheter versus surgical valve replacement in patients with severe aortic stenosis in Latin America.

In elderly (75 years or older) patients living in Latin America with severe symptomatic aortic stenosis candidates for transfemoral approach, the panel suggests the use of transcatheter aortic valve implant (TAVI) over surgical aortic valve replacement (SAVR). This is a conditional recommendation, based on moderate certainty in the evidence (⨁⨁⨁Ο).This recommendation does not apply to patients in which there is a standard of care, like TAVI for patients at very high risk for cardiac surgery or inoperable patients, or SAVR for non-elderly patients (eg, under 65 years old) at low risk for cardiac surgery. The suggested age threshold of 75 years old is based on judgement of limited available literature and should be used as a guide rather than a determinant threshold.The conditional nature of this recommendation means that the majority of patients in this situation would want a transfemoral TAVI over SAVR, but some may prefer SAVR. For clinicians, this means that they must be familiar with the evidence supporting this recommendation and help each patient to arrive at a management decision integrating a multidisciplinary team discussion (Heart Team), patient's values and preferences through shared decision-making, and available resources. Policymakers will require substantial debate and the involvement of various stakeholders to implement this recommendation.

Clinical outcome in nonagenarians undergoing transcatheter valve replacement.

BACKGROUND: Nonagenarians are mostly denied from different therapeutic strategies due to high preoperative risk. We present the results of nonagenarians with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). METHODS: Our retrospective analysis include baseline and procedural data along with clinical outcome. Clinical follow-up was performed in all patients after TAVR. RESULTS: Out of 689 patients, 33 nonagenarians with a mean age of 90.9±1.4years suffering from severe AS and elevated comorbidity index (logistic EuroSCORE of 16.3±9.6%, STS score 11.1±9.9%) underwent TAVR between September 2009 and July 2016 using self-expanding prosthesis. Baseline transthoracic echocardiography reported a mean aortic valve area (AVA) of 0.64±0.12cm2 with a mean pressure gradient of 56.1±16.1mmHg. Five (16.2%) patients had postprocedural moderate/severe aortic regurgitation. One patient died intraoperally due to ventricular perforation during predilatation, while two patients died within the first 30days, one due to cardiogenic shock and the other due to pneumonia. No patient experienced a myocardial infarction or a stroke, while ten (30.3%) required permanent pacemaker placement. At follow-up (mean 20.3 months, range 1-78 months), all cause and cardiovascular mortality was 24.2% and 15.1%, respectively. Two patients presented heart failure and 12 (40%) had exertional dyspnea. By echo, mean valve area was 1.72±0.12cm2 and mean gradient 11.2±1.4mmHg. Two patients (16.7%) presented moderate aortic regurgitation. CONCLUSION: Our case series demonstrate that even with elevated comorbidity index, clinical endpoints and valve-associated results are relatively favorable in nonagenarians treated with TAVR.

Fractura de stent liberador de sirolimus / Sirolimus-Eluting stent Fracture

La fractura del stent es una complicación que se ha comunicado luego del implante de stents liberadores de sirolimus con una frecuencia que oscila entre el 1,9% y el 16% según las series y que se asocia con una tasa mayor de reestenosis y de eventos cardíacos a largo plazo. En esta presentación se describe el caso de un paciente en el que, casi 6 años después del implante de dos stents liberadores de sirolimus telescopados, a través de tomografia computarizada multidetector y angiografía invasiva se evidenció la fractura de los stents telescopados, asociada con oclusión del stent.

The reported incidence of stent fracture after sirolimuseluting stent implantation ranges from 1.9 to 16% according to different series. It has been associated with increased rate of restenosis and long-term cardiac events. We describe the case of a patient with a telescoped stent fracture associated with stent occlusion, after 6 years of telescoped sirolimus-eluting stent implantation. It was detected using multislice computed tomography and invasive angiography.

Fractura de stent liberador de sirolimus / Sirolimus-Eluting stent Fracture

La fractura del stent es una complicación que se ha comunicado luego del implante de stents liberadores de sirolimus con una frecuencia que oscila entre el 1,9% y el 16% según las series y que se asocia con una tasa mayor de reestenosis y de eventos cardíacos a largo plazo. En esta presentación se describe el caso de un paciente en el que, casi 6 años después del implante de dos stents liberadores de sirolimus telescopados, a través de tomografia computarizada multidetector y angiografía invasiva se evidenció la fractura de los stents telescopados, asociada con oclusión del stent.(AU)

The reported incidence of stent fracture after sirolimuseluting stent implantation ranges from 1.9 to 16% according to different series. It has been associated with increased rate of restenosis and long-term cardiac events. We describe the case of a patient with a telescoped stent fracture associated with stent occlusion, after 6 years of telescoped sirolimus-eluting stent implantation. It was detected using multislice computed tomography and invasive angiography.(AU)

Oclusão percutânea do apêndice atrial esquerdo com o Amplatzer Cardiac PlugTM na fibrilação atrial / Percutaneous occlusion of left atrial appendage with the Amplatzer Cardiac PlugTM in atrial fibrillation

Fundamento: A fibrilação atrial está associada a acidentes vasculares embólicos que frequentemente resultam em morte ou invalidez. Eficaz na redução desses eventos, a anticoagulação possui várias limitações e vem sendo amplamente subutilizada. Mais de 90 por cento dos trombos identificados nos portadores de fibrilação atrial sem doença valvar se originam no apêndice atrial esquerdo, cuja oclusão é investigada como uma alternativa à anticoagulação. Objetivo: Determinar a viabilidade da oclusão percutânea do apêndice atrial esquerdo em pacientes com alto risco de eventos embólicos e limitações ao uso de anticoagulação. Métodos: Relatamos a experiência inicial com o Amplatzer Cardiac PlugTM (St. Jude Medical Inc., Saint Paul, Estados Unidos) em pacientes com fibrilação atrial não valvar. Foram selecionados pacientes com alto risco de tromboembolia, sangramentos maiores e contraindicações ao uso ou grande labilidade na resposta ao anticoagulante. Os procedimentos foram realizados por via percutânea, sob anestesia geral e com ecocardiografia transesofágica. O desfecho primário foi a presença de complicações periprocedimento e o seguimento programado incluiu reavaliação clínica e ecocardiográfica em 30 dias e por contato telefônico após nove meses. Resultados: Nos cinco pacientes selecionados se conseguiu a oclusão do apêndice atrial esquerdo sem complicações periprocedimento. Não houve eventos clínicos no seguimento. Conclusão: Ensaios clínicos controlados são necessários antes que o fechamento percutâneo do apêndice atrial esquerdo constitua uma alternativa à anticoagulação na fibrilação atrial não associada a doença valvar. Mas o dispositivo se mostrou promissor em pacientes com alto risco de embolia e restrições ao uso de anticoagulantes.

Background: Atrial fibrillation is associated with embolic strokes that often result in death or disability. Effective in reducing these events, anticoagulation has several limitations and has been widely underutilized. Over 90 percent of thrombi identified in patients with atrial fibrillation without valvular disease originate in the left atrial appendage, whose occlusion is investigated as an alternative to anticoagulation. Objective: To determine the feasibility of percutaneous occlusion of the left atrial appendage in patients at high risk of embolic events and limitations to the use of anticoagulation. Methods: We report our initial experience with Amplatzer Cardiac PlugTM (St. Jude Medical Inc., Saint Paul, Estados Unidos) in patients with nonvalvular atrial fibrillation. We selected patients at high risk of thromboembolism, major bleeding, contraindications to the use or major instability in response to the anticoagulant. The procedures were performed percutaneously under general anesthesia and transesophageal echocardiography. The primary outcome was the presence of periprocedural complications and follow-up program included clinical and echocardiographic review within 30 days and by telephone contact after nine months. Results: In five selected patients it was possible to occlude the left atrial appendage without periprocedural complications. There were no clinical events in follow-up. Conclusion: Controlled clinical trials are needed before percutaneous closure of the left atrial appendage should be considered an alternative to anticoagulation in nonvalvular atrial fibrillation. But the device has shown to be promissory in patients at high risk of embolism and restrictions on the use of anticoagulants.

Percutaneous occlusion of left atrial appendage with the Amplatzer Cardiac PlugTM in atrial fibrillation.

BACKGROUND: Atrial fibrillation is associated with embolic strokes that often result in death or disability. Effective in reducing these events, anticoagulation has several limitations and has been widely underutilized. Over 90% of thrombi identified in patients with atrial fibrillation without valvular disease originate in the left atrial appendage, whose occlusion is investigated as an alternative to anticoagulation. OBJECTIVE: To determine the feasibility of percutaneous occlusion of the left atrial appendage in patients at high risk of embolic events and limitations to the use of anticoagulation. METHODS: We report our initial experience with Amplatzer Cardiac Plug™ (St. Jude Medical Inc., Saint Paul, Estados Unidos) in patients with nonvalvular atrial fibrillation. We selected patients at high risk of thromboembolism, major bleeding, contraindications to the use or major instability in response to the anticoagulant. The procedures were performed percutaneously under general anesthesia and transesophageal echocardiography. The primary outcome was the presence of periprocedural complications and follow-up program included clinical and echocardiographic review within 30 days and by telephone contact after nine months. RESULTS: In five selected patients it was possible to occlude the left atrial appendage without periprocedural complications. There were no clinical events in follow-up. CONCLUSION: Controlled clinical trials are needed before percutaneous closure of the left atrial appendage should be considered an alternative to anticoagulation in nonvalvular atrial fibrillation. But the device has shown to be promissory in patients at high risk of embolism and restrictions on the use of anticoagulants.

Reemplazo percutáneo de la válvula aórtica en pacientes con estenosis aórtica grave y riesgo quirúrgico elevado / Percutaneous Aortic Valve Replacement in Patients with Severe Aortic Stenosis and High Surgical Risk / Percutaneous Aortic Valve Replacement in Patients with Severe Aortic Stenosis and High Surgical Risk

Introducción La cirugía de reemplazo valvular aórtico es el tratamiento de elección en pacientes con estenosis aórtica. Sin embargo, en una proporción considerable de pacientes, el riesgo quirúrgico y la presencia de algunas comorbilidades, que aumentan este riesgo, impiden la cirugía. El reemplazo percutáneo de la válvula aórtica representa una alternativa a la cirugía valvular convencional para pacientes seleccionados de riesgo elevado. Objetivo Comunicar la experiencia inicial de reemplazo percutáneo de la válvula aórtica con prótesis autoexpandible CoreValve® (Medtronic, Minneapolis, MN, USA) en pacientes portadores de estenosis aórtica grave. Material y métodos Registro multicéntrico en el que se incluyeron 21 pacientes con estenosis aórtica grave (área < 1 cm²) sintomática y riesgo quirúrgico elevado sometidos a implante percutáneo en cuatro centros cardiovasculares argentinos de alta complejidad. Para el procedimiento se implementó una estrategia multidisciplinaria que involucró a diversos especialistas: anestesiólogo, cirujano, expertos en imágenes y cardiólogos intervencionistas. Resultados La edad media fue de 80,8 ± 7,1 años (rango: 63-90), el 57% de sexo masculino, área valvular media de 0,59 ± 0,25 cm² y EuroSCORE de 18,1% ± 4%. El 73% y el 27% de los pacientes se encontraban en clase funcional III y IV, respectivamente. El éxito del procedimiento fue del 95,2% (20/21), que se tradujo en una reducción pronunciada del gradiente pico transvalvular aórtico (82 ± 14 mm Hg a 12 ± 3 mm Hg; p < 0,001), mientras que el desarrollo posprocedimiento de regurgitación aórtica de grado moderado-grave fue del 14%. El 85,8% de los pacientes evolucionaron a clase funcional I. El requerimiento de marcapasos definitivo fue del 38% (8/21). La mortalidad del procedimiento y a los 30 días fue del 4,7% y del 9,5%, respectivamente; se observó un caso de accidente cerebrovascular isquémico menor con restitución ad integrum dentro de la semana. Se detectaron 4 óbitos en el seguimiento alejado (mediana 7 meses), dos de origen cardíaco (mortalidad cardíaca 19%) y otros dos de causa no cardíaca. Conclusiones El tratamiento de la estenosis aórtica grave en pacientes de riesgo quirúrgico elevado mediante reemplazo valvular percutáneo con prótesis CoreValve® es una alternativa factible que se asocia con una mejoría funcional notoria. La selección adecuada de pacientes, el perfeccionamiento de la técnica del procedimiento y el desarrollo de nuevos diseños incrementarán su eficacia y seguridad.

Background Aortic valve replacement is the treatment of choice in patients with aortic stenosis. However, a significant number of patients are not candidates for surgery due to high surgical risk and to the presence of comorbidities. Percutaneous aortic valve replacement represents an alternative option to conventional aortic valve surgery for selected high risk patients. Objective To inform about the initial experience with percutaneous aortic valve replacement with a self-expanding CoreValve® aortic valve prosthesis (Medtronic, Minneapolis, MN, USA). Material and Methods We conducted a multicenter registry including 21 patients with severe symptomatic aortic stenosis (aortic valve area < 1 cm²) and high surgical risk undergoing percutaneous aortic valve replacement in four high complexity cardiovascular centers. A multidisciplinary strategy was used involving several specialists: anesthesiologist, surgeon, diagnostic images specialists and interventional cardiologists. Results Mean age was 80.8±7.1 years (range: 63-90); 57% were men. Mean aortic valve area was 0.59±0.25 cm² and mean EuroSCORE was 18.1%±4%. The percentages of patients in functional class III and IV were 73% and 27%, respectively. The procedure was successful in 95.2% (20/21) of patients, with a pronounced reduction in peak transvalvular aortic gradient (from 82±14 mm Hg to 12±3 mm Hg; p <0,001); 14% of patients developed moderate to severe aortic regurgi-tation after the procedure. 85.5% of patients evolved to FC I. Definite pacemaker implantation was required in 38% (8/21). Procedure-related mortality was 4.7% and mortality after 30 days was 9.5%. One patient developed a minor stroke with complete recovery within a week. Four patients died in the long-term follow-up (median 7 months): 2 due to cardiac causes (cardiac mortality 19%) and 2 due to non-cardiac causes. Conclusions Percutaneous aortic valve replacement with CoreValve® aortic valve prosthesis is a feasible option for patients with high surgical risk that is associated with significant clinical improvement. The adequate selection of patients, improvement of the surgical technique and the development of new designs will increase the efficacy and safeness of the procedure.

Experiência inicial com novo amplatzer TM cardiac plug para oclusão percutânea do apêndice atrial esquerdo / Initial experience with the new amplatzer TM cardiac plug for percutaneous closure of the left atrial appendage

Introdução: A formação de trombos no apêndice atrial esquerdo (AAE) constitui a principal causa de fenômenos tromboembólicos em pacientes com fibrilação atrial (FA). A anticoagulação oral é considerada terapia de primeira linha na prevenção de tromboembolismo associado à FA. Apesar de comprovada eficácia, a terapia com anticoagulantes orais está associada a inúmeras limitações. A oclusão percutânea do AAE surgiu como uma nova estratégia para prevenção de acidentes vasculares cerebrais em pacientes com FA considerados de alto risco e não candidatos a tratamento com anticoagulantes. Métodos: Relatamos a experiência inicial da oclusão percutânea do AAE utilizando o novo dispositivo AmplatzerTM Cardiac Plug (ACP – AGA Medical Corp., Golden Valley, Estados Unidos) em pacientes com FA e escore CHADS2 > 2, não elegíveis à terapêutica com anticoagulantes. Os procedimentos foram realizados sob anestesia geral e monitoração por ecocardiografia transesofágica tridimensional em tempo real. Resultados: Três pacientes do sexo masculino, com média de idade de 79 anos e escores CHADS2 2, 3 e 5, foram submetidos a implante do dispositivo por via transeptal sem complicações, resultando em oclusão imediata do AAE e alta hospitalar após dois dias. No seguimento de 50 dias, todos os pacientes se apresentavam bem clinicamente e a ecocardiografia transtorácica confirmou oclusão total do AAE e ausência de complicações. Conclusões: A oclusão percutânea do AAE com ACP parece ser uma alternativa terapêutica atrativa na prevenção de eventos tromboembólicos em pacientes com FA e contraindicações ou limitações para anticoagulação oral.

Background: Thrombus formation in the left atrial appendage (LAA) is the main cause of thromboembolic events in patients with non-valvular atrial fibrillation (AF). Oral anticoagulantsare considered first-line therapy for stroke prevention in AF patients. Despite its proven efficacy, long-term oral anticoagulation is associated to innumerous limitations. PercutaneousLAA closure has emerged as a new strategy for stroke prevention in high risk AF patients who are not candidatesfor long term oral anticoagulation therapy. Methods: We report the initial experience with percutaneous occlusionof the LAA using the new AmplatzerTM Cardiac Plug (ACP – AGA Medical Corp., Golden Valley, USA) in patients withAF and CHADS2 score > 2 who were not eligible for anticoagulation therapy. Procedures were carried out undergeneral anesthesia and 3D transesophageal echocardiographymonitoring in real time. Results: Three male patients, mean age of 79 years and CHADS2 2, 3 and 5 scores had thedevice successfully implanted using a transeptal approach with no complications, resulting in immediate LAA occlusion and hospital discharge two days later. At the 50-day followup,all patients were clinically well with complete LAA occlusion and no complications at transthoracic echocardiography. Conclusions: Percutaneous LAA occlusion with thenew ACP seems to be an attractive alternative to prevent thromboembolic events in patients with AF and contraindications or limitations for anticoagulation therapy.

Avaliação da resolução do supradesnivelamento do segmento ST após angioplastia primária, registro multicêntirco de infarto agudo do miocárdio com supradesnivelamento do segmento ST na Argentina / Evaluation of st segment elevation resolution after primary angioplasty: results of a multicenter registry of acute myocardial infarction with ST segment elevation in Argentina

A magnitude da resolução do supradesnivelamento do segmento ST é um marcador de reperfusão miocárdica em pacientes com infarto agudo do miocárdio. A resolução incompleta do supradesnivelamento do segmento ST foi identificada como preditor de resultados desfavoráveis em pacientes com infarto agudo do miocárdio após terapia de reperfusão. Este estudo teve como objetivos descrever a frequência de resolução incompleta do supradesnivelamento do segmento ST em um registro contemporâneo de pacientes submetidos a angioplastia primária e fazer uma comparação de seus resultados hospitalares com pacientes que apresentaram resolução completa do supradesnivelamento do segmento ST. Método: Entre julho de 2008 e fevereiro de 2009, foram incluídos 183 pacientes consecutivos com infarto agudo do miocárdio (< 24 horas) de oito centros na Argentina em um registro prospectivo de infarto agudo do miocárdio com supradesnivelamento do segmento ST foi definida como redução < ou igual 70 por cento do supradesnivelamento do segmento ST no eletrocardiograma...

Uso de tromboaspiração em angioplastia coronária primária no mundo real: registro multicêntrico argentino de infarto agudo do miocárdio com supradesnivelamento do segmento ST / Real world use of thrombus-aspiration during primary angioplasty: argentinean multicenter registry of ST-elevation myocardial infarction

INTRODUÇÃO: O uso de tromboaspiração manual demonstrou melhorar a reperfusão miocárdica durante a intervenção percutânea primária. Entretanto, a população adequada para esse tratamento ainda não foi bem estabelecida. Este estudo teve como objetivo determinar a taxa de utilização e a seleção de pacientes para tromboaspiração manual durante intervenção percutânea primária. MÉTODO: No período de julho de 2008 a fevereiro de 2009, incluímos 183 pacientes com intervenção percutânea primária de oito centros argentinos em um registro prospectivo de infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). As características clínicas, angiográficas e do procedimento e os desfechos clínicos foram comparados entre os pacientes tratados com e sem tromboaspiração manual. RESULTADOS: A tromboaspiração manual foi utilizada em 20,8% dos pacientes. As características clínicas basais foram, em geral, semelhantes entre os pacientes tratados com e sem tromboaspiração manual. Entretanto, os pacientes tratados com tromboaspiração manual tinham pior função renal pré-procedimento e maior somatória de supradesnivelamento do segmento ST basal (12,2 ± 7,7 mm vs. 10,2 ± 8,6 mm; P = 0,06). O grupo com tromboaspiração manual apresentou maior proporção de pacientes com trombo graus 4-5 (86,8% vs. 49%; P < 0,01), maior fluxo TIMI 0 basal (tromboaspiração manual: 63,2% vs. 40,7%; P = 0,03), maior diâmetro do vaso (3,46 ± 0,5 mm vs. 3,12 ± 0,5 mm; P = 0,01), e maior utilização de filtro distal (13,1% vs. 0,7%; P = 0,04) e de balão intra-aórtico (10,5% vs. 3,4%; P = 0,05), assim como de inibidores da glicoproteína IIb/IIIa (39,5% vs. 14,5%; P = 0,04). A taxa de resgate de material aterotrombótico macroscópico foi de 76,3%. Embora o grupo com tromboaspiração manual apresentasse pico mais elevado de creatina fosfoquinase (tromboaspiração manual: 3.195,9 ± 2.598 UI/ml vs. 1.757,6 ± 1.806,6 UI/ml; P = 0,02), a porcentagem de resolução do segmento ST e o fluxo TIMI 3 final não foram diferentes entre os grupos. A taxa de eventos cardiovasculares adversos maiores no acompanhamento foi semelhante (21,1% vs. 15,2%; P = 0,36). CONCLUSÃO: O emprego da tromboaspiração manual na prática diária em paciente com IAMCSST destina-se a pacientes de maior complexidade tanto clínica como angiográfica, acarretando, no final, resultados clínicos semelhantes aos de pacientes não tratados com tromboaspiração manual.

BACKGROUND: Manual thrombus-aspiration has proven to improve myocardial reperfusion during primary percutaneous coronary intervention. However, the adequate population for this approach has not been well established. The aim of this study was to determine the frequency and patient selection for thrombus-aspiration during primary percutaneous coronary intervention. METHOD: From July 2008 to February 2009, we included 183 patients submitted to primary percutaneous coronary intervention from eight Argentinean centers in a prospective ST-segment elevation myocardial infarction (STEMI) registry. Baseline characteristics as well as clinical and angiographic outcomes were compared among patients treated with and without thrombus-aspiration. RESULTS: Manual thrombus-aspiration was used in 20.8% of the patients. Baseline clinical characteristics were similar among patients treated with and without thrombus-aspiration. However, thrombus-aspiration treatment was associated with worse baseline renal function and greater baseline ST-segment elevation (thrombus-aspiration: 12.2 ± 7.7 mm vs. 10.2 ± 8.6 mm; P = 0.06). The thrombus-aspiration group had a higher rate of patients with grade 4-5 thrombus (86.8% vs. 49%; P < 0.01) and baseline TIMI flow 0 (thrombus-aspiration 63.2% vs. 40.7%; P = 0.03), greater vessel diameter (3.46 ± 0.5 mm vs. 3.12 ± 0.5 mm; P = 0.01), use of distal filter (13.1% vs. 0.7%; P = 0.04) and use of intra-aortic balloon (10.5% vs 3.4%; P = 0.05), as well as glycoprotein IIb/IIIa inhibitor administration (39.5% vs. 14.5%; P = 0.04). Debris was retrieved from 76.3% of the patients. Although the thrombus-aspiration group had higher CK levels (thrombus-aspiration: 3195.9 ± 2598 UI/ml vs. 1757.6 ± 1806.6 UI/ml; P = 0.02), the percentage of ST-segment resolution and final TIMI 3 flow did not differ between groups. The follow-up rate of major cardiovascular events was similar for both groups (thrombusaspiration: 21.1% vs. 15.2%; P = 0.36). CONCLUSION: Routine thrombus-aspiration in patients with STEMI is used in patients with higher clinical and angiographic complexity, leading to similar overall clinical results as those not treated with thrombus-aspiration.

Culprit-only or multivessel percutaneous coronary stenting in patients with non-ST-segment elevation acute coronary syndromes: one-year follow-up.

OBJECTIVE: To investigate the major cardiac events at 1-year follow-up of multivessel versus culprit-vessel stenting in patients presenting with non-ST elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). INTRODUCTION: Percutaneous coronary intervention is a standard revascularization strategy for patients with NSTE-ACS. However, when these patients have MVD it is not clear whether multivessel (MVR) is superior to culprit-vessel revascularization (CVR). METHODS: We screened 1,100 consecutive patients with NSTE-ACS from an institutional database. Comparisons of 1-year outcomes between multivessel and culprit-vessel revascularized patients were made. The primary outcome was the composite (MACE) of death, myocardial infarction (MI), or any revascularization. Secondary end-points were the components of the composite end-point. Regression analysis was performed to detect predictors of MACE. RESULTS: A total of 609 patients were considered for this analysis: 204 (33.5%) and 405 (66.5%) had MVR and CVR treatment, respectively. The strategy adopted was based on a clinical decision. The incidence of MACE was lower in MVR (9.45% vs. 16.34%, P = 0.02) with lower revascularization rate (7.46% vs. 13.86%, P = 0.04) than in CVR. There was no difference in death (1.99% vs. 1.98%, P = 0.8) nor death/MI (2.49% vs. 3.22%, P = 0.8) between MVR and CVR, respectively. Multivariate analysis showed CVR as the only independent predictor of improved MACE (OR 0.66, CI95% 1.12-3.47, P = 0.01). CONCLUSION: Multivessel stenting in patients with NSTE-ACS and multivessel disease using a clinical decision of treatment is associated with lower rate of MACE driven by lower repeat revascularization, compared with culprit-vessel stenting, without difference in rates of death or MI.

Predictores de reperfusión miocárdica tisular luego de la angioplastia en el infarto agudo de miocardio / Predictors of Myocardial Tissue Reperfusion after Angioplasty in Acute Myocardial Infarction

Introducción La angioplastia primaria tiene una eficacia limitada ya que deja a un grupo considerable de pacientes sin lograr una reperfusión miocárdica tisular adecuada. Los factores clínicos, angiográficos y terapéuticos que influyen en el grado de reperfusión no han sido claramente establecidos. Objetivos Identificar los factores independientes asociados con la ausencia de reperfusión tisular luego de la angioplastia primaria. Material y métodos Se analizaron 140 pacientes incluidos prospectivamente en el estudio aleatorizado Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction Trial (PREMIAR). Este estudio evaluó la utilización de un filtro de protección distal durante la angioplastia en el infarto agudo de miocardio con supradesnivel del segmento ST en pacientes de alto riesgo trombótico (solamente incluyendo flujo coronario basal TIMI 0-2). El punto final primario fue la resolución completa del segmento ST a los 60 minutos, definida como disminución del ST ≥ 70% con el empleo de monitorización continua del segmento ST. Se desarrolló un modelo de regresión logística para identificar los predictores independientes. Resultados Se observó resolución completa del segmento ST a los 60 minutos luego de la angioplastia en 82 pacientes (63%), mientras que 53 pacientes (37%) presentaron resolución incompleta que se asoció con una tasa de mortalidad, reinfarto y/o insuficiencia cardíaca a los 30 días del 8,5% y 18,9%, respectivamente (p = 0,07). Los pacientes que no lograron una reperfusión tisular adecuada tuvieron con más frecuencia compromiso de localización anterior (79% versus 33%; p = 0,001), mayor frecuencia cardíaca (81 ± 20 versus 70 ± 15; p < 0,001) y menor proporción de fumadores actuales (25% versus 51%; p = 0,002) respecto de aquellos con reperfusión tisular óptima. Se observó además una tendencia a mayor presencia de diabetes (26% versus 16%; p = 0,13), mayor tiempo desde el inicio de los síntomas a la angioplastia (minutos) (217 ± 167 versus 182 ± 134; p = 0,19) y clase Killip > 1 (30% versus 17%; p = 0,07), respectivamente. El análisis multivariado demostró que el infarto de localización anterior (OR 8,22, IC 95% 3,67-18,4; p < 0,001) se asoció con ausencia de reperfusión completa, mientras que el uso de inhibidores de la glicoproteína IIb/IIIa (OR 4,21, IC 95% 1,34-13,22; p = 0,014) y el tabaquismo actual (OR 3,84, IC 95% 1,58-9,50; p = 0,003) se correlacionaron con una reperfusión completa. Conclusiones Una proporción considerable de pacientes sometidos a angioplastia primaria no logran una reperfusión tisular adecuada. Este fenómeno se asocia con peor pronóstico. La presencia de infarto de localización anterior se correlaciona con una extensión menor del grado de reperfusión tisular. Contrariamente, el tabaquismo actual y el uso de inhibidores de la glicoproteína IIb/IIIa se asocian con una reperfusión tisular más profunda luego de la angioplastia primaria.

Background The efficacy of primary angioplasty is limited due to the fact that a considerable number of patients do not achieve adequate levels of myocardial tissue perfusion. The degree of reperfusion depends on multiple clinical, angiographic and therapeutic factors. Objectives To identify the independent factors associated with the absence of myocardial tissue reperfusion after primary angioplasty. Material and Methods A total of 140 patients included in the Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction Trial (PREMIAR) were analyzed. This study evaluated the use of filter distal protection device during angioplasty in patients with acute STsegment elevation myocardial infarction at high risk of thrombosis (only including baseline TIMI grade 0-2 flow). The primary end point of the study was the rate of complete ST-segment resolution at 60 minutes, defined as ≥ 70% recovery compared with baseline during continuous ST-segment monitoring. A model of logistic regression was developed to identify independent predictors. Results Complete resolution of ST-segment deviation 60 minutes after angioplasty was observed in 82 patients (63%), while 53 patients (37%) presented partial ST-segment resolution which was associated with rates of mortality, reinfarction and/or heart failure at 30 days of 8.5% and 18.9%, respectively (p=0.07). The variables associated with absence of adequate myocardial tissue reperfusion were anterior infarction (79% versus 33%; p=0.001), higher heart rate (81±20 versus 70±15; p=0.001) and history of current smoking (25% versus 51%; p=0.002), compared to optimal tissue reperfusion. In addition, there was a trend towards greater prevalence of diabetes (26% versus 16%; p=0.13), longer time interval from the onset of symptoms to angioplasty (minutes) (217±167 versus 182±134; p=0.19) and Killip class >1 (30% versus 17%; p=0.07), respectively. Multivariate analysis demonstrated that anterior myocardial infarction was associated with absence of complete reperfusion (OR 8.22, 95% CI 3.67-18.4; p<0.001), while the use of glycoprotein IIb/IIIa inhibitors (OR 4.21, 95% CI 1.34-13.22; p=0.014) and current smoking (OR 3.84, 95% CI 1.58-9.50; p=0.003) correlated with complete reperfusion. Conclusions A considerable proportion of patients undergoing primary angioplasty do not achieve adequate myocardial tissue reperfusion. This phenomenon is associated with adverse outcomes. Anterior myocardial infarction correlates with less degree of tissue reperfusion. Conversely, current smoking and the use of glycoprotein IIb/IIIa inhibitors are associated with better tissue reperfusion after primary angioplasty.

Multicenter randomized comparison of direct vs. conventional stenting: the DIRECTO trial.

With conventional stenting, predilatation frequently induces dissections that require deploying stents longer than originally planned. To assess whether direct stenting is safe and may prevent dissections and reduce the length of stents implanted, we conducted a randomized study comparing direct (n = 73) and conventional (n = 78) stenting. Direct stenting was successful in 89% of cases, 11% crossed over to predilation without complications. Dissections occurred more frequently in conventional stenting group (10.3% vs. 1.4%; P = 0.034), but did not translate to a significant stent length difference (16.31 +/- 7.6 vs. 15.31 +/- 5.5; P = NS). Periprocedure creatine kinase elevation and number of balloons utilized were lower with direct stenting.