Randomized comparison of distal and proximal cerebral protection during carotid artery stenting.

OBJECTIVES: This study sought to randomly compare cerebral protection with ANGIOGUARD (Cordis Corporation, Bridgewater, New Jersey) with Mo.Ma (Invatec/Medtronic Vascular Inc, Santa Rosa, California) during carotid artery stenting (CAS), using diffusion-weighted magnetic resonance imaging (DW-MRI) to detect new ischemic cerebral lesions. The number, size, and location of lesions were analyzed. BACKGROUND: The choice of the type of cerebral protection during CAS is controversial. METHODS: From July 2008 to July 2011, 60 patients undergoing CAS were randomized to ANGIOGUARD or Mo.Ma, distributed by chance, 30 patients for each group. All patients underwent DW-MRI before and after CAS. An independent neuroradiologist blinded to the cerebral protection used analyzed the images. Univariate and multivariate logistic models were fitted to analyze new ischemic lesions. Alternatively, a propensity score approach was used to reduce the bias due to differences between the groups. For the number of lesions, we used Poisson regression models. RESULTS: New ischemic lesions seen on DW-MRI were present in 63.3% of the ANGIOGUARD group versus 66.7% of the Mo.Ma cohort (p = 0.787). The number of ischemic cerebral lesions per patient, when present, was significantly lower in the Mo.Ma group (a median of 6 lesions per patient vs. a median of 10 in the ANGIOGUARD, p < 0.001). Most lesions were small (<0.5 mm) and localized in the ipsilateral territory. One patient in the ANGIOGUARD group had a minor stroke during CAS (1.66%). CONCLUSIONS: New ischemic lesions seen on DW-MRI were present in both groups in >60%, but the number of lesions per patient was greater in the ANGIOGUARD group. No death or disabling stroke occurred during at least 1 year of follow-up in both cohorts.

Randomized comparison of distal and proximal cerebral protection during carotid artery stenting

Objectives This study sought to randomly compare cerebral protection with ANGIOGUARD (CordisCorporation, Bridgewater, New Jersey) with Mo.Ma (Invatec/Medtronic Vascular Inc, Santa Rosa,California) during carotid artery stenting (CAS), using diffusion-weighted magnetic resonance imaging(DW-MRI) to detect new ischemic cerebral lesions. The number, size, and location of lesions wereanalyzed.Background The choice of the type of cerebral protection during CAS is controversial.Methods From July 2008 to July 2011, 60 patients undergoing CAS were randomized toANGIOGUARD or Mo.Ma, distributed by chance, 30 patients for each group. All patients underwentDW-MRI before and after CAS. An independent neuroradiologist blinded to the cerebral protectionused analyzed the images. Univariate and multivariate logistic models were fitted to analyze newischemic lesions. Alternatively, a propensity score approach was used to reduce the bias due todifferences between the groups. For the number of lesions, we used Poisson regression models.Results New ischemic lesions seen on DW-MRI were present in 63.3% of the ANGIOGUARD groupversus 66.7% of the Mo.Ma cohort (p » 0.787). The number of ischemic cerebral lesions per patient,when present, was significantly lower in the Mo.Ma group (a median of 6 lesions per patient vs.a median of 10 in the ANGIOGUARD, p 60%, but thenumber of lesions per patient was greater in the ANGIOGUARD group. No death or disabling strokeoccurred during at least 1 year of follow-up in both cohorts.

Risk factors for stroke after coronary artery bypass grafting.

BACKGROUND: Stroke is a feared complication after coronary artery bypass grafting surgery (CABG), with an incidence between 1.3 and 4.3%. OBJECTIVE: To identify predictive factors for stroke after CABG in the modern era of cardiac surgery. METHODS: This is a case-control study of 65 pairs of patients, paired by sex, age (+ 3 years) and date of CABG (+ 3 months). The cases were patients submitted to elective CABG with extracorporeal circulation (ECC) that presented stroke (defined as clinical neurological deficit up to 24 hours post-operatively and confirmed by imaging assessment) and the controls were those individuals submitted to elective CABG with ECC, but without stroke. RESULTS: The univariate analysis demonstrated that the number of revascularized vessels was associated with the occurrence of stroke after the CABG (3 +/- 0.8 vs. 2.76 +/- 0.8, p = 0.01). The multivariate analysis by conditional logistic regression showed that systemic arterial hypertension (SAH) [OR: 6.1 (1.5 - 24), p = 0.009] and diabetes mellitus (DM) [OR: 3.1 (1.09 - 11), p= 0.03] were the determinants of the highest chance of stroke after CABG, whereas acute myocardial infarction (AMI) > 1 month, was the determinant of the lowest chance of stroke [OR: 0.1 (0.03 - 0.36), p = 0.003]. CONCLUSION: Hypertension and diabetes mellitus were identified as independent predictors of stroke within the first 24 postoperative hours after CABG. In patients with such risk factors, it is possible that the knowledge of the causal mechanisms of brain injury represents a strategy capable of decreasing the incidence of stroke after CABG.

Fatores de risco para acidente vascular encefálico após cirurgia de revascularização do miocárdio / Risk factors for stroke after coronary artery bypass grafting

FUNDAMENTO: O acidente vascular encefálico (AVE) é uma temida complicação após cirurgia de revascularização do miocárdio (CRM), com incidência entre 1,3 por cento e 4,3 por cento. OBJETIVO: Identificar fatores preditores de AVE após CRM, na era moderna da cirurgia cardíaca. MÉTODOS: Este é um estudo caso-controle de 65 pares de pacientes, no qual o pareamento foi realizado por sexo, idade (+ 3 anos) e data da CRM (+ 3 meses). Os casos são pacientes submetidos à CRM eletiva com circulação extracorpórea (CEC), que apresentaram AVE (definido como déficit clínico neurológico até 24 horas de pós-operatório e confirmado por exame de imagem), e os controles aqueles submetidos à CRM eletiva com CEC sem AVE. RESULTADOS: A análise univariada revelou que o número de vasos revascularizados foi associado com a ocorrência de AVE após a CRM (3 ± 0,8 vs. 2,76 ± 0,8, p = 0,01). Na análise multivariada por regressão logística condicional, a hipertensão arterial sistêmica [OR: 6,1 (1,5 - 24), p = 0,009] e o diabete melito [OR: 3,1 (1,09 - 11), p= 0,03] foram determinantes de maior chance de AVE após CRM, e o infarto agudo do miocárdio > 1 mês determinante de menor chance [OR: 0,1 (0,03 - 0,36), p = 0,003]. CONCLUSÃO: Hipertensão e diabete melito foram identificados como preditores independentes de AVE nas primeiras 24 horas de pós-operatório de CRM. Em pacientes com tais fatores de risco, é possível que o conhecimento dos mecanismos causadores da injúria cerebral represente uma estratégia capaz de diminuir a incidência de AVE após CRM.

BACKGROUND: Stroke is a feared complication after coronary artery bypass grafting surgery (CABG), with an incidence between 1.3 and 4.3 percent. OBJECTIVE: To identify predictive factors for stroke after CABG in the modern era of cardiac surgery. METHODS: This is a case-control study of 65 pairs of patients, paired by sex, age (+ 3 years) and date of CABG (+ 3 months). The cases were patients submitted to elective CABG with extracorporeal circulation (ECC) that presented stroke (defined as clinical neurological deficit up to 24 hours post-operatively and confirmed by imaging assessment) and the controls were those individuals submitted to elective CABG with ECC, but without stroke. RESULTS: The univariate analysis demonstrated that the number of revascularized vessels was associated with the occurrence of stroke after the CABG (3 ± 0.8 vs. 2.76 ± 0.8, p = 0.01). The multivariate analysis by conditional logistic regression showed that systemic arterial hypertension (SAH) [OR: 6.1 (1.5 - 24), p = 0.009] and diabete mellitus (DM) [OR: 3.1 (1.09 - 11), p= 0.03] were the determinants of the highest chance of stroke after CABG, whereas acute myocardial infarction (AMI) > 1 month, was the determinant of the lowest chance of stroke [OR: 0.1 (0.03 - 0.36), p = 0.003]. CONCLUSION: Hypertension and diabete mellitus were identified as independent predictors of stroke within the first 24 postoperative hours after CABG. In patients with such risk factors, it is possible that the knowledge of the causal mechanisms of brain injury represents a strategy capable of decreasing the incidence of stroke after CABG.

Ablação percutânea da artéria septal no tratamento da cardiomiopatia hipertrófica / Septal arteries percutaneous ablation in hypertrofic cardiomiopathy therapy

A cardiomiopatia hipertrófica obstrutiva (CMHO) é uma doença caracterizada por obstrução dinâmica da via de saída do ventrículo esquerdo (VSVE), devido a desarranjo de fibras musculares predominantemente no septo interventricular. A ablação da artéria septal (AAS) tem se constituído numa alternativa a cirurgia de miomectomia no tratamento da CMHO. Realizamos este procedimento (AAS) em dez pacientes no período de março/98 a julho/2001. Houve sucesso em todos os pacientes (100%). O gradiente médio teve importante redução (88mmHg para 5mmHg). No segmento clínico todos os pacientes encontram-se assintomáticos e não houve recidiva da obstução. Ao ecocardiograma observamos remodelamento da VSVE caracterizado por alargamento da mesma, não havendo mais hipertrofia significativa septal.