Complicación infrecuente tras implante percutáneo de válvula aórtica / Rare complication after transaortic percutaneous valve implantation

No disponible

Nitroprusiato: una droga confiable para la estimación de la reserva de flujo fraccional coronario / Nitroprusside: a reliable drug for fractional flow reserve assessment

La angiografía coronaria permanece como "gold standard" para el diagnóstico y toma de decisiones en la enfermedad coronaria. Sin embargo, la significación de lesiones con estenosis de 50-70 por ciento es difícil. La medición de la reserva de flujo fraccional (FFR) es una herramienta útil para dilucidar esta interrogante. Generalmente se usa adenosina (A) en bolo intracoronario para inducir máxima vasodilatación y hay poca evidencia para drogas alternativas con este objeto. En este estudio evaluamos el uso de nitroprusiato (N) como droga alternativa. Métodos y Resultados: Se efectuó un estudio clínico aleatorizado. A (120 ug IC) y posteriormente N (50 ug IC), o vice-versa, se usaron para evaluar cada lesión. Se evaluaron 60 lesiones en 44 pacientes (24 hombres) de 63.5 +/- 9.6 años, con masa corporal 28.95 +/- 3.32 kg/m2. Las lesiones se localizaron en arteria descendente anterior en 46.7 por ciento, coronaria derecha en 26.7 por ciento, circunfleja en 11.7 por ciento y 13.9 por ciento en las otras arterias. La estenosis coronaria promedio evaluada por angiografía cuantitativa fue 49.5 por ciento (95 por ciento CI: 46.5 - 52.5 por ciento). La presión arterial media (PAM) basal fue similar en ambos grupos (pre - A: 106.5 +/- 18.2 mmHg, pre - N: 105.6 +/- 18.8 mmHg, NS) o después de A, pero se observó un descenso transitorio después de NP (descenso promedio de 12.5 mmHg, 95 por ciento CI: 9.2 a15.7 mmHg, 2p < 0.001). Este efecto estaba asociado a la hiperemia prolongada lograda con N. (duración de hiperemia con N: 39.2 +/- 8.7 s., y con A of 15.3 +/- 3.2 s. 2p < 0.001). Hubo excelente correlación entre los resultados de A y de N respecto de FFR (r 0.986)...

Abstract: Coronary angiography remains the gold standard for diagnosing coronary artery disease and making therapeutic decisions. However the significance of intermediate lesions (between 50-70%) is difficult to evaluate. Fractional flow reserve (FFR) measurement is an important tool for the evaluation of these lesions. To achieve maximum vasodilatation, Intracoronary (IC) bolus or a continuous intravenous infusion of (A) is usually used. There is very little data for an alternative drug. The aim of this study was to evaluate Sodium nitroprusside (N) 50 IC bolus as an alternative to A for to determine FFR.Method and Results: A multicentric, randomized clinical trial was conducted. A, (120 IC) and subsequently N (50 IC) or vice versa was used for every lesion. 60 coronary lesions were evaluated in 44 patients (24 men and 20 women), mean age 63.5 ± 9.6 years and BMI 28.95 ± 3.32 kg/m2. The lesions were located in the left anterior descending artery in 46.7% of patients, the right coronary in 26.7%, the circumflex in 11.7% and others in 13.9%. Mean coronary artery stenosis as assessed by quantitative coronary angiography (QCA) was 49.5% (95% CI: 46.5 - 52.5%).The mean arterial pressure (MAP) was similar in groups at baseline.(pre - A: 106.5 ± 18.2 mmHg, pre - N: 105.6 ± 18.8 mmHg, NS), or after A, but there was a transient decrease in MAP when N was administered (average decline of MAP: 12.5 mmHg, (95% CI: 9.2 to 15.7 mmHg, 2p < 0.001). This effect was due to the prolonged hypere-mia time achieved with the drug (hyperemia duration with nitroprusside 39.2 ± 8.7 sec. and with adenosine of 15.3 ± 3.2 sec. 2p < 0.001). We could demonstrate an excellent correlation between IC nitroprusside and IC adenosine with regard to FFR measurement, (correlation coefficient = 0.986, p < 0.001)...

Extremely high-pressure dilation with a new noncompliant balloon.

Calcified nondilatable lesions remain a challenge for the interventional cardiologist, and they are becoming more frequent in the catheterization laboratory as the overall complexity of interventions increases. Stent underexpansion is the main risk factor for restenosis and thrombosis, which is the most feared complication for the interventionalist.In this report, we present our initial experience (8 patients) with a new noncompliant high-pressure balloon, the OPN NC balloon, a double-layered device. When we used this device at 40 atm, our rate of success was reasonable (75%) and our patients experienced no adverse sequelae. The OPN NC balloon appears to offer a new means of dilating lesions or underexpanded stents when other noncompliant balloons have failed. Safety seems reasonable, even at pressures as high as 40 atm.

Comparación de angiografía coronaria rotacional de doble eje (XPERSWING) frente a técnica convencional en la práctica habitual / Comparison of Dual-axis rotational coronary angiography (XPERSWING) versus conventional technique in routine practice

Introducción y objetivos. La coronariografía es la técnica de elección para estudiar la enfermedad coronaria. El estudio con esta técnica requiere varias proyecciones ortogonales. La angiografía rotacional es una nueva técnica que realiza una rotación del tubo de rayos alrededor del paciente sobre un doble eje que permite la visualización desde diferentes ángulos de cada coronaria con una única inyección de contraste. El objetivo es comparar la angiografía convencional (A) con la angiografía rotacional (B) analizando dosis de radiación, cantidad de contraste administrado y tiempo de procedimiento, tanto en el procedimiento diagnóstico como en el terapéutico. Métodos. Estudio prospectivo de 104 pacientes consecutivos aleatorizados a ambos grupos. Resultados. Encontramos reducción significativa de contraste (A frente a B, 93,1 ± 41,7 frente a 50,9 ± 14,7ml; p < 0,0001) y de dosis de radiación (27,6 ± 11,5 frente a 18 ± 6,4 mGycm; p < 0,0001). Hubo un aumento significativo en el tiempo de procedimiento diagnóstico. Sin embargo, cuando analizamos a los últimos 50 pacientes, desaparecen las diferencias en el tiempo de procedimiento, probablemente debido a la curva de aprendizaje. Se realizó angioplastia a 29 pacientes del grupo A y 28 del grupo B, en el que se mantuvo la reducción de contraste (A frente a B, 335,1 ± 192,1 frente a 238,5 ± 114,4ml; p = 0,02). Conclusiones. La angiografía rotacional permite una reducción significativa de la dosis de radiación y la cantidad de contraste administrado en procedimientos diagnósticos respecto a la angiografía convencional. En los pacientes a los que se realiza intervencionismo percutáneo, la reducción de contraste persiste significativamente (AU)

Introduction and objectives. Coronary angiography is the gold standard for the study of coronary artery disease. This technique requires several orthogonal projections. Rotational angiography is a new technique which involves pre-set rotation of the X-ray tube around the patient and allows visualization of each coronary artery in different views, using a single contrast injection. The purpose of this study was to compare conventional coronary angiography (A) vs rotational angiography (B), focusing on radiation dose, amount of contrast administered, and total procedure time for both diagnostic and therapeutic percutaneous coronary interventions. Methods. Prospective study of 104 consecutive patients undergoing coronary angiography who were randomized to one of these techniques. Results. We found a significant reduction in the amount of contrast administered (A vs B, 93.1 [41.7] vs 50.9 [14.7] mL; P<.0001) and radiation exposure (27.6 [11.5] vs 18 [6.4] mGycm; P<.0001). A significant increase in total procedure time was noted in the rotational angiography arm. However, when only the last 50 patients were analyzed, we found no difference in procedure time between the groups, probably related to the learning curve of the operators. Angioplasty was performed in 29 patients in group A and 28 patients in group B. Contrast reduction was maintained in the rotational angiography group compared to the conventional technique (A vs B, 335.1 [192.1] vs 238.5 [114.4] mL; P=.02). Conclusions. The rotational angiography technique leads to a significant decrease in radiation exposure and contrast dose administered for diagnostic procedures when compared to conventional coronary angiography. In patients who undergo percutaneous coronary intervention, contrast reduction remains significant (AU)

Comparison of dual-axis rotational coronary angiography (XPERSWING) versus conventional technique in routine practice.

INTRODUCTION AND OBJECTIVES: Coronary angiography is the gold standard for the study of coronary artery disease. This technique requires several orthogonal projections. Rotational angiography is a new technique which involves pre-set rotation of the X-ray tube around the patient and allows visualization of each coronary artery in different views, using a single contrast injection. The purpose of this study was to compare conventional coronary angiography (A) vs rotational angiography (B), focusing on radiation dose, amount of contrast administered, and total procedure time for both diagnostic and therapeutic percutaneous coronary interventions. METHODS: Prospective study of 104 consecutive patients undergoing coronary angiography who were randomized to one of these techniques. RESULTS: We found a significant reduction in the amount of contrast administered (A vs B, 93.1 [41.7] vs 50.9 [14.7] mL; P<.0001) and radiation exposure (27.6 [11.5] vs 18 [6.4] mGycm(2); P<.0001). A significant increase in total procedure time was noted in the rotational angiography arm. However, when only the last 50 patients were analyzed, we found no difference in procedure time between the groups, probably related to the learning curve of the operators. Angioplasty was performed in 29 patients in group A and 28 patients in group B. Contrast reduction was maintained in the rotational angiography group compared to the conventional technique (A vs B, 335.1 [192.1] vs 238.5 [114.4] mL; P=.02). CONCLUSIONS: The rotational angiography technique leads to a significant decrease in radiation exposure and contrast dose administered for diagnostic procedures when compared to conventional coronary angiography. In patients who undergo percutaneous coronary intervention, contrast reduction remains significant.

Safety and efficacy of tirofiban as adjunctive therapy for patients with ST-elevation myocardial infarction: a comparison versus placebo and abciximab.

Tirofiban is a nonpeptide tyrosine derivative that together with eptifibatide (both small molecules) and abciximam belongs to the group of glycoprotein IIb/IIIa inhibitors. Though similar to abciximab in that it has a high affinity for the GP IIbIIIa inhibitor receptor, tirofiban dissociates from it much faster tan abciximab, what makes its action reversible in a few hours. Initially used upstream for treatment of patients with non ST-elevation acute coronary síndromes, recent evidence has shown its role as adjuntive therapy in patients with ST-elevation acute myocardial infarction treated with primary angioplasty when used at a higher dose. In this article, we performed a thorough and systematic review of randomized trials comparing tirofiban versus pacebo and tirofiban versus abciximab when used in this subset of patients. All these studies showed tirofiban to be a well tolerated and effective IIbIIIa inhibitor. When compared with placebo, tirofiban was associated with a significant reduction in mortality and myocardial infarction at one month, with a higher risk of minor bleeding in the follow-up. When compared with abciximab, tirofiban showed no difference in mortality and a tendency to higher rate of the composite of death and myocardial infarction in the short term follow-up that disappeared when only studies with high-dose tirofiban were considered. On the basis of the high-dose regimen, tirofiban may be considered useful in the management of patients with ST-elevation myocardial infarction who undergo primary angioplasty.

Predictors and prognostic value of myocardial injury following stent implantation.

BACKGROUND: Troponin I concentrations are frequently elevated following percutaneous coronary intervention (PCI) even in procedures without complications and are considered, by some, as predictive of long-term morbidity and mortality. We assessed whether post-PCI troponin I concentrations bore any relationship to clinical, angiographic and in-laboratory minor adverse events indicative of myocardial injury and evaluated, in follow-up, whether these levels are useful as a predictive markers of adverse events. METHODS: Patients (n=147) who were scheduled for PCI for stent placement were prospectively studied. In-laboratory events recorded were protracted chest pain, electrocardiographic changes, slow flows, dissections and lateral branch affectation. Troponin I and creatinine kinase MB fraction (CK-MB) mass were measured at baseline and post-procedure. Mean clinical follow-up was for 10.4+/-3.6 months. RESULTS: During PCI, at least one adverse event occurred in 34% of patients and, in 38% of them, there was an elevation of troponin I as compared to 5.1% of those patients without any adverse event (relative risk=7.4; P<0.001). Elevation of troponin I concentrations occurred in 16.3% of all patients, 79.2% associated with an AE. CK-MB was elevated in 15.6% of patients. On multivariate analysis, protracted chest pain, lateral branch involvement and slow flow remained statistically significant in relation to post-procedure elevations of troponin I concentrations. Clinical follow-up showed a poorer prognosis in patients who had had elevated troponin I concentrations. CONCLUSIONS: In-laboratory adverse event predict elevated post-procedure troponin I concentrations which are associated with myocardial injury. These elevations, in turn, predict poorer medium-term clinical outcomes.