Osteoblastoma of the clavicle at the site of a previous fracture-first case report and review of the literature.

Osteoblastoma is a rare, benign primary tumor of bone, accounting for < 1% of all bone tumors. We report the case of a 27-year-old female who developed pain and swelling five and a half years after a clavicular fracture and was subsequently found to have an osteoblastoma arising at the fracture site. This is the first reported case of an osteoblastoma developing after a fracture, although osteoid osteomas, which are histologically indistinguishable from osteoblastomas, have been reported at prior fracture sites. This report demonstrates that secondary neoplasms such as osteoblastomas should be considered in the differential diagnosis for pain at a healed fracture site recurring years after the initial trauma.

Prospective comparison between three TAVR devices: ACURATE neo vs. CoreValve vs. SAPIEN XT. A single heart team experience in patients with severe aortic stenosis.

OBJECTIVE: We sought to compare the new transcatheter aortic valve replacement (TAVR) device ACURATE neo (ACT) with the already established CoreValve (MCV) and SAPIEN XT (SXT) for the treatment of severe aortic stenosis (AS). BACKGROUND: Very few data on TAVR devices are available beyond MCV and SAPIEN and there is no previous study comparing ACT with MCV and SXT. METHODS: We prospectively evaluated consecutive patients who underwent transfemoral TAVR for the treatment of severe AS. Clinical outcomes were reported following Valve Academic Research Consortium 2 (VARC-2) criteria. RESULTS: A total of 162 patients (ACT n = 49, MCV n = 56, SXT n = 57), were included. MCV group had higher valve embolization/migration rates (ACT none; MCV 9%; SXT 2%; P = 0.034) causing lower device success rates (ACT 98%; MCV 86%; SXT 95%; P = 0.043). At 30 days, there was no significant difference in all-cause mortality (P = 0.22), cardiovascular mortality (P = 0.20), periprocedural myocardial infarction (P = 0.40), stroke (P = 0.64), major vascular complications (P = 0.48), life-threatening bleeding (P = 0.29), acute kidney injury stage 2/3 (P = 0.69), or VARC-2 composite early safety endpoints (P = 0.21). MCV group had higher rates of new permanent pacemaker implantation (ACT 6%; MCV 25%; SXT 11%; P = 0.013). Follow-up echocardiography showed no significant difference in aortic valve mean pressure gradient (P = 0.73) or moderate/severe aortic regurgitation (P = 0.19) between groups. CONCLUSIONS: In a "real world" registry, ACT compared favorably against the well-studied SXT and MCV devices in both safety and efficacy. MCV implantation was associated with lower device success rates and higher rates of new permanent pacemaker implantation. © 2016 Wiley Periodicals, Inc.

Prospective comparison between three TAVR devices: ACURATE neo vs. CoreValve vs. SAPIEN XT. A single heart team experience in patients with severe aortic stenosis

OBJECTIVE: We sought to compare the new transcatheter aortic valve replacement (TAVR) device ACURATE neo (ACT) with the already established CoreValve (MCV) and SAPIEN XT (SXT) for the treatment of severe aortic stenosis (AS). BACKGROUND: Very few data on TAVR devices are available beyond MCV and SAPIEN and there is no previous study comparing ACT with MCV and SXT. METHODS: We prospectively evaluated consecutive patients who underwent transfemoral TAVR for the treatment of severe AS. Clinical outcomes were reported following Valve Academic Research Consortium 2 (VARC-2) criteria.RESULTS:A total of 162 patients (ACT n = 49, MCV n = 56, SXT n = 57), were included. MCV group had higher valve embolization/migration rates (ACT none; MCV 9%; SXT 2%; P = 0.034) causing lower device success rates (ACT 98%; MCV 86%; SXT 95%; P = 0.043). At 30 days, there was no significant difference in all-cause mortality (P = 0.22), cardiovascular mortality (P = 0.20), periprocedural myocardial infarction (P = 0.40), stroke (P = 0.64), major vascular complications (P = 0.48), life-threatening bleeding (P = 0.29), acute kidney injury stage 2/3 (P = 0.69), or VARC-2 composite early safety endpoints (P = 0.21). MCV group had higher rates of new permanent pacemaker implantation (ACT 6%; MCV 25%; SXT 11%; P = 0.013). Follow-up echocardiography showed no significant difference in aortic valve mean pressure gradient (P = 0.73) or moderate/severe aortic regurgitation (P = 0.19) between groups...

Impacto da Curva de Aprendizado na Seleção de Pacientes e nos Resultados Clínicos do Implante por Cateter de Prótese Aórtica / Impact of Transcatheter Aortic Valve Implantation Learning Curve on Patient Selection and Clinical Outcomes

Introdução: O implante por cateter de prótese aórtica (TAVI, do inglês transcatheter aortic valve implantation) constitui tratamento alternativo para pacientes com estenose aórtica de alto risco cirúrgico ou inoperáveis. Para adquirir competência, o grupo multidisciplinar deve receber treinamento específico e acumular experiência na execução do TAVI. Contudo, sua curva de aprendizado não está bem estabelecida. Nosso objetivo foi analisar o impacto da curva de aprendizado na seleção de pacientes, nos aspectos técnicos e nos resultados clínicos do TAVI. Métodos: Estudo observacional e prospectivo dos primeiros 150 pacientes submetidos a TAVI por via femoral, entre janeiro de 2009 e dezembro de 2013 divididos em tercis (n = 50) de acordo com a data do procedimento. Os desfechos foram definidos conforme os critérios Valve Academic Research Consortium-2 (VARC-2). Resultados: A idade foi de 82,5 ± 6,7 anos, sendo 44% homens e 75% em classe NYHA III/IV. O EuroSCORE (24,2 ± 13% vs. 21,2 ± 10,8% vs. 23,4 ± 14,3%) e o STS Score (5,9 ± 2,9% vs. 6,7 ± 4,3% vs. 5,8 ± 3,1%) foram similares entre os grupos. Observou-se redução gradativa nos tempos do procedimento (107,2 ± 48,1 minutos vs. 90,3 ± 42,2 minutos vs. 76,6 ± 37,7 minutos; p < 0,01) e de fluoroscopia (31,3 ± 9,6 minutos vs. 25,4 ± 8,7 minutos vs. 17,2 ± 6,2 minutos; p = 0,01), e no ...

Background: Transcatheter aortic valve implantation (TAVI) is an alternative treatment for high-risk or inoperable patients with aortic stenosis. The multidisciplinary team must undergo specific training and accumulate experience to achieve optimal results. However, its learning curve is not well established. Our objective was to investigate the impact of learning curve on patient selection, technical aspects and clinical outcomes of TAVI. Methods: Observational, prospective analysis of the first 150 patients undergoing transfemoral TAVI between January 2009 and December 2013. Patients were divided into tertiles (n = 50), according to the procedure date. Outcomes were defined according to Valve Academic Research Consortium-2 (VARC-2) criteria. Results: Mean age was 82.5 ± 6.7 years, 44% were male and 75% were in NYHA class III/IV. EuroS-CORE (24.2 ± 13% vs. 21.2 ± 10.8% vs. 23.4 ± 14.3%) and STS Score (5.9 ± 2.9% vs. 6.7 ± 4.3% vs. 5.8 ± 3.1%) were similar between groups. A gradual decrease was observed in procedure times (107.2 ± 48.1 minutes vs. 90.3 ± 42.2 minutes vs. 76.6 ± 37.7 minutes; p < 0.01), fluoroscopy times (31.3 ± 9,6 minutes vs. 25.4 ± 8.7 minutes vs. 17.2 ± 6.2 minutes; p = 0.01) and contrast volume (145.5 ± 70.9 mL vs. 123.2 ± 87.8 mL vs. 101.1 ± 50 mL; p = 0.01). Mortality decreased gradually (20% vs. 10% vs. 4%; p = 0,047), and lower bleeding and moderate-to-severe aortic regurgitation were ...

Incidence and predictors of very late (>or=4 years) major cardiac adverse events in the DESIRE (Drug-Eluting Stents in the Real World)-Late registry.

OBJECTIVES: Our aim was to access the incidence of late major adverse cardiac events (MACE) and stent thrombosis (ST) in nonselected, complex patients followed for a period >/=4 years. BACKGROUND: Despite the efficacy of drug-eluting stents (DES) in reducing repeated target lesion revascularization, concerns regarding the occurrence of late and very late ST have partially obscured the benefits of this novel technology. METHODS: All consecutive patients treated solely with DES between May 2002 and January 2005 were enrolled into this prospective, nonrandomized, single-center registry. The primary end point was long-term occurrence of MACE up to 7 years. Independent predictors of MACE, cardiac death, target lesion revascularization, and ST were obtained by a multivariate Cox proportional hazards regression model. RESULTS: A total of 1,010 patients were enrolled. Most of them were men (77%) with a mean age of 63.7 years. Stent/patient rate was 1.4. Patients were kept in dual antiplatelet therapy for 3 and 6 months after Cypher (Cordis, Johnson & Johnson, Miami Lakes, Florida) and Taxus (Boston Scientific Corp., Natick, Massachusetts) stent implantation, respectively. Follow-up was obtained in 98.2% of the cohort (median 5.01 years). Survival free of MACE and cumulative incidence of definite/probable ST were 84.6% and 1.7%, respectively. Independent predictors of ST were percutaneous coronary intervention in the setting of acute myocardial infarction, DES overlapping, treatment of multivessel disease, presence of moderate-to-severe calcification at lesion site, and in-stent residual stenosis. CONCLUSIONS: The deployment of DES in complex, real-world patients resulted in a low rate of very long-term MACE and ST. However, ST still occurs very long after the index procedure.

Implante de stent farmacológico para o tratamento da reestenose de outro stent farmacológico: análise tardia do registro DESIRE / Drug-Eluting Stent Implantation for the Treatment of Drug-Eluting Stent Restenosis: Long-Term Analysis of the DESIRE Registry

Fundamentos: Apesar da notória redução nas taxas de reestenose (RIS) com os stents farmacológicos (SF), essa complicação ainda ocorre em 5 por cento a 25 por cento dos casos. A história natural e o melhor tratamento para a reestenose de SF ainda não estão definidos. Método: Entre maio de 2002 e novembro de 2007, todos os pacientes com RIS de SF tratados com outro SF foram consecutivamente incluídos neste registro. O tipo de SF implantado para tratar a RIS ficou a critério do operador. Acompanhamento clínico foi obtido com 1 , 6 e 12 meses e, então, anualmente. O objetivo primário foi avaliar a incidência acumulada de eventos cardíacos maiores (ECAM). Resultados: Dos 45 pacientes (53 lesões) tratados percutaneamente com outro SF, 66,6 por cento eram do sexo masculino. Diabetes melito foi observado em 35,5 por cento desses pacientes. A maioria das reestenosis foi do tipo focal (75 por cento). O diâmetro de referência do vaso tratado e a extensão da lesão foram de 2,99 + - 0,5 mm e 11,33 + - 5,8 mm, respectivamente. Em 28 por cento dos casos optou-se por implantar um SF diferente daquele que apresentou RIS. Sucesso angiográfico foi obtido em 100 por cento dos casos. Seguimento clínico foi obtido em toda a população...

Background: Despite the marked reduction in restenosis rates following drug-eluting stent (DES) use, this complication still happens in 5%-25% of the cases. The natural history and the best treatment for DES in-stent restenosis are still to be defined. Methods: Between May 2002 and November 2007, all consecutive cases of DES restenosis treated with another DES were included in this registry. The type of DES to be deployed was at the surgeon's discretion. Follow-up data were obtained at 1, 6, and 12 months and then annually. The primary endpoint of this study was the incidence of combined major cardiac events (MACE). Results: Of the 45 patients (53 lesions) submitted to new percutaneous coronary intervention (PCI) with DES, 66.6% were men. Diabetes mellitus was observed in 35.5% of the patients. Most in-stent restenosis were focal (75%). Reference vessel diameter and lesion length were 2.99 ± 0.5 mm and 11.33 ± 5.8 mm, respectively. A different type of DES was preferred in 28% of the cases. Angiographic success was achieved in all cases. Clinical data of all population were obtained (mean 2.7 ± 1.1 years). In the long term, the cumulative rate of MACE was 13.3%, and 5 (11.1%) patients manifested recurrent symptoms. Conclusions: The use of a DES to treat a previous DES in-stent restenosis represents a safe and efficient approach, with low rates of adverse events in the short and long terms.

Long-term clinical outcomes of the Drug-Eluting Stents in the Real World (DESIRE) Registry.

BACKGROUND: Recently, cardiologists have treated more complex patients and lesions with drug-eluting stents (DES). However, long-term efficacy and safety of the off-label use of these new devices is yet to be demonstrated. METHODS: The Drug-Eluting Stents in the Real World (DESIRE) registry is a prospective, nonrandomized single-center registry with consecutive patients treated solely with DES between May 2002 and May 2007. The primary end-point was long-term occurrence of major adverse cardiac events (MACE). Patients were clinically evaluated at 1, 3, and 6 months and then annually up to 5 years. RESULTS: A total of 2,084 patients (2,864 lesions and 3,120 DES) were included. The mean age was 63.8 +/- 11.5 years. Diabetes was detected in 28.9% and 40.7% presented with acute coronary syndrome. Cyphertrade mark was the predominant DES in this registry (83.5%). Mean follow-up time was 2.6 +/- 1.2 years and was obtained in 96.5% of the eligible patients. Target lesion revascularization (TLR) was performed in 3.3% of the patients. Q wave myocardial infarction (MI) occurred in only 0.7% of these patients and total stent thrombosis rate was 1.6% (n = 33). Independent predictors of thrombosis were PCI in the setting of MI (HR 11.2; 95% CI, 9.6-12.4, P = 0.001), lesion length (HR 4.6; 95% CI, 3.2-5.3, P = 0.031), moderate to severe calcification at lesion site (HR 13.1; 95% CI, 12.1-16.7, P < 0.001), and in-stent residual stenosis (HR 14.5; 95% CI, 10.2-17.6, P < 0.001). CONCLUSION: The use of DES in unselected population is associated with long-term safety and effectiveness with acceptable low rates of adverse clinical events.

Drug-eluting stents vs bare metal stents for the treatment of large coronary vessels

Background Lately drug-eluting stents (DES) have dramatically reduced restenosis rates and need for repeat revascularization in a wide subset of lesion and patients. However, their benefit for the treatment of large vessels (N3.0 mm)

has yet to be established. Objective We investigated whether DES are superior to bare metal stents (BMS) in terms of clinical outcomes for the treatment of large coronary vessels. Methods This study assessed the long-term outcomes (cardiac death, acute myocardial infarction, and need for repeat

intervention in the treated vessel) of patients treated with either a DES (Cypher and Taxus) or a BMS of z3.5 mm in diameter. A total of 250 consecutive patients who underwent DES implantation were clinically followed for 1 year and compared to

250 patients who were treated with BMS. Interventions in the setting of acute ST elevation myocardial infarction and treatment of bypass grafts were excluded. Results Cypher was the DES deployed in 70.8% of cases. Most of the enrolled patients were men (78%) with single

vessel disease (65.6%). The left anterior descending artery was the culprit vessel in 34.2% of cases. Bare metal stent and DES cohorts had equivalent interpolated reference vessel diameter (3.19 F 0.3 mm for BMS vs 3.18 F 0.2 for DES; P = .1).

Lesion was significantly longer in the group treated with DES (13.4 F 5.1 mm for BMS group vs 14.3 F 3.5 for DES; P = .0018). After 1 year of clinical follow-up, 95.2% of patients treated with DES and 91.2% of the patients who received BMS

were free of major events ( P = .2). A trend toward higher target-lesion revascularization was noticed in the group treated with BMS (4.8% vs 1.6%; P = .07). Conclusion Percutaneous treatment of large coronary vessels carries a low risk of clinical events irrespective of the type

Drug-eluting stents vs bare metal stents for the treatment of large coronary vessels.

BACKGROUND: Lately drug-eluting stents (DES) have dramatically reduced restenosis rates and need for repeat revascularization in a wide subset of lesion and patients. However, their benefit for the treatment of large vessels (> 3.0 mm) has yet to be established. OBJECTIVE: We investigated whether DES are superior to bare metal stents (BMS) in terms of clinical outcomes for the treatment of large coronary vessels. METHODS: This study assessed the long-term outcomes (cardiac death, acute myocardial infarction, and need for repeat intervention in the treated vessel) of patients treated with either a DES (Cypher and Taxus) or a BMS of > or = 3.5 mm in diameter. A total of 250 consecutive patients who underwent DES implantation were clinically followed for 1 year and compared to 250 patients who were treated with BMS. Interventions in the setting of acute ST elevation myocardial infarction and treatment of bypass grafts were excluded. RESULTS: Cypher was the DES deployed in 70.8% of cases. Most of the enrolled patients were men (78%) with single vessel disease (65.6%). The left anterior descending artery was the culprit vessel in 34.2% of cases. Bare metal stent and DES cohorts had equivalent interpolated reference vessel diameter (3.19 +/- 0.3 mm for BMS vs 3.18 +/- 0.2 for DES; P = .1). Lesion was significantly longer in the group treated with DES (13.4 +/- 5.1 mm for BMS group vs 14.3 +/- 3.5 for DES; P = .0018). After 1 year of clinical follow-up, 95.2% of patients treated with DES and 91.2% of the patients who received BMS were free of major events (P = .2). A trend toward higher target-lesion revascularization was noticed in the group treated with BMS (4.8% vs 1.6%; P = .07). CONCLUSION: Percutaneous treatment of large coronary vessels carries a low risk of clinical events irrespective of the type of stent used.

A intervenção coronária percutânea para o tratamento dos coronarianos estáveis: evidências e tomada de decisão / Coronary percutaneous intervention for the threatment of stable coronary patients: evidences and decision making

A angina estável, forma mais comum de apresentação clínica da doença aterosclerótica coronária, ainda hoje responde por elevados índices de morbidade e mortalidade na população mundial, fato que continuamente tem estimulado os cardiologistas a pesquisarem novas formas de combatê-los, quer por meio do desenvolvimento de novos fármacos como do aprimoramento das técnicas de revascularização percutânea e cirúrgica. A Cardiologia intervencionista, ao longo de seus 25 anos de existência, vem oferecendo opções de tratamento percutâneo cada vez mais eficientes e menos invasivas para os portadores de doença coronária crônica, desde a era dos balões até os atuais stents eluídos em medicação, sendo hoje capaz de modificar de forma segura e eficaz a história natural dessa afecção.

Percutaneous implantation of endoprostheses in the carotid arteries.

OBJECTIVE: To assess the in-hospital evolution of patients undergoing percutaneous stent placement in the carotid arteries. METHODS: From August 1996 to April 2001, we studied 86 patients with carotid arterial obliterative lesions > 70% who were treated with percutaneous stent placement in the carotid arteries. We assessed the rate of success of the implantation and of the procedure, the types of stents used, mortality rate, and neurological complications. RESULTS: Successful implantation was obtained in 98.9% of the cases, and the procedure was successful in 91.8%. The Wallstent was the most frequently used stent (73 patients - 77%). Cerebral strokes occurred as follows: 3 (3.2%) transient ischemic attacks, 1 (1.1%) minor stroke, and 3 (3.1%) major strokes. One (1.1%) patient died during hospitalization. CONCLUSION: The high rate of success of stent implantation (98.9%) in addition to the low rate of cerebral stroke/death (4.2%) showed the efficiency and safety of percutaneous stent placement in carotid arteries.

Implante percutâneo de endopróteses nas artérias carótidas / Percutaneous implantation of endoprostheses in the carotid arteries

OBJECTIVE: To assess the in-hospital evolution of patients undergoing percutaneous stent placement in the carotid arteries. METHODS: From August 1996 to April 2001, we studied 86 patients with carotid arterial obliterative lesions > 70 percent who were treated with percutaneous stent placement in the carotid arteries. We assessed the rate of success of the implantation and of the procedure, the types of stents used, mortality rate, and neurological complications. RESULTS: Successful implantation was obtained in 98.9 percent of the cases, and the procedure was successful in 91.8 percent. The Wallstent was the most frequently used stent (73 patients - 77 percent). Cerebral strokes occurred as follows: 3 (3.2 percent) transient ischemic attacks, 1 (1.1 percent) minor stroke, and 3 (3.1 percent) major strokes. One (1.1 percent) patient died during hospitalization. CONCLUSION: The high rate of success of stent implantation (98.9 percent) in addition to the low rate of cerebral stroke/death (4.2 percent) showed the efficiency and safety of percutaneous stent placement in carotid arteries

Implante percutâneo de endopróteses nas artérias carótidas com uso adjunto de filtros para a proteção cerebral: experiência inicial / Carotide arteries endosprothesis percutaneous implant with filters adjunct use for cerebral protection: Initial experience

Objetivos: Avaliar a evolução hospitalar de pacientes submetidos a implante percutâneo de stents nas artérias carótidas (ISC) com uso adjunto de filtros para a proteção cerebral. Métodos: No período de dezembro de 2001 a agosto de 2002 estudamos 14 pacientes que apresentaram lesão obstrutiva significativa na artéria carótida e foram tratados com ISC. Mensuramos o sucesso do implante , do procedimento, os tipos de stents utilizados, os tipos de filtros utilizados, a mortalidade e as complicações neurológicas relacionadas ao procedimento. Resultados: O sucesso do implante e do procedimento foi alcançado em 100% dos casos. O stent mais utilizado foi o WALLSTENT carotídeo em 12 pacientes (85,7%). Não houve acidente vascular cerebral (AVC) transitório, AVC maior e AVC menor...