Efficacy and Safety of Stents in ST-Segment Elevation Myocardial Infarction.

BACKGROUND: To date, no specific drug-eluting stent (DES) has fully proven its superiority over others in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention. OBJECTIVES: The purpose of this study was to compare the safety and efficacy of coronary artery stents in STEMI patients in a patient-level network meta-analysis. METHODS: Eligible studies were dedicated randomized controlled trials comparing different stents in STEMI patients undergoing percutaneous coronary intervention with at least 12 months of clinical follow-up. Of 19 studies identified from the published data, individual patient data were collected in 15 studies with 10,979 patients representing 87.7% of patients in the overall network of evidence. The primary endpoint was the composite of cardiac death, reinfarction, or target lesion revascularization. RESULTS: Overall, 8,487 (77.3%) of 10,979 STEMI patients were male and the mean age was 60.7 years. At a median follow-up of 3 years, compared with bare-metal stents (BMS), patients treated with paclitaxel-, sirolimus-, everolimus-, or biolimus-eluting stents had a significantly lower risk of the primary endpoint (adjusted hazard ratios [HRs]: 0.74 [95% confidence interval (CI): 0.63 to 0.88], 0.65 [95% CI: 0.49 to 0.85], 0.70 [95% CI: 0.53 to 0.91], and 0.66 [95% CI: 0.49 to 0.88], respectively). The risk of primary endpoint was not different between patients treated with BMS and zotarolimus-eluting stents (adjusted HR: 0.83 [95% CI: 0.51 to 1.38]). Among patients treated with DES, no significant difference in the risk of the primary outcome was demonstrated. Treatment with second-generation DES was associated with significantly lower risk of definite or probable stent thrombosis compared with BMS (adjusted HR: 0.61 [95% CI: 0.42 to 0.89]) and first-generation DES (adjusted HR: 0.56 [95% CI: 0.36 to 0.88]). CONCLUSIONS: In STEMI patients, DES were superior to BMS with respect to long-term efficacy. No difference in long-term efficacy and safety was observed among specific DES. Second-generation were superior to first-generation DES in reducing stent thrombosis. (Clinical Outcomes After Primary Percutaneous Coronary Intervention [PCI] Using Contemporary Drug-Eluting Stent [DES]: Evidence From the Individual Patient Data Network Meta-Analysis; CRD42018104053).

Prótesis SAPIEN XT sobre SAPIEN XT estenótica / SAPIEN XT Valve-in-valve implantation in stenotic valve

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VERifyNow in DIabetes high-on-treatment platelet reactivity: a pharmacodynamic study on switching from clopidogrel to prasugrel.

INTRODUCTION: Diabetic patients with an acute coronary syndrome undergoing percutaneous coronary intervention frequently exhibit high platelet reactivity while on clopidogrel. We hypothesized that in diabetic patients undergoing percutaneous coronary intervention, who exhibit high-platelet-reactivity after standard treatment with clopidogrel, a 60-mg prasugrel loading dose is superior to standard treatment with clopidogrel for optimal P2Y12 inhibition within the first 24-36 h post-angioplasty. METHODS: VERDI was a prospective, randomized, single-centre, single-blind, parallel-design study (NCT01684813). Consecutive diabetic patients with an non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention and loaded with clopidogrel were considered for platelet reactivity assessment immediately before angioplasty with the VerifyNow assay measured in P2Y12 reaction units (PRU). Fifty of 63 screened patients (79.4%) had high platelet reactivity (PRU ≥ 208) and were randomized to receive a 60-mg prasugrel loading dose (n = 25) versus clopidogrel standard dose (n = 25). Platelet function was assessed again 24 hours post-angioplasty. RESULTS: Prasugrel achieved greater platelet inhibition than clopidogrel 24 hours post-angioplasty (median [interquartile range], 38 [9-72] vs 285 [240-337], respectively; P < 0.001). The non-high-platelet-reactivity rate (PRU < 208) at 24 h post-angioplasty (primary end point) was higher with prasugrel; 25 patients (100%) in the prasugrel group achieved optimal antiaggregation vs 4 patients (16%) in the clopidogrel group (P < 0.001). No significant acute bleeding was documented in either group. CONCLUSION: Among type 2 diabetic patients suffering an acute coronary syndrome with high-platelet-reactivity undergoing percutaneous coronary intervention, switching from clopidogrel to prasugrel was superior to standard treatment with clopidogrel for the achievement of optimal antiaggregation within the first 24 hours post-angioplasty.

A comparative study of bivalirudin plus clopidogrel versus bivalirudin plus prasugrel in primary angioplasty using propensity score matching.

INTRODUCTION AND OBJECTIVES: In primary angioplasty, bivalirudin is superior to treatment with heparin plus glycoprotein inhibitors for reducing cardiovascular events, although bivalirudin increases the risk of stent thrombosis. Our hypothesis is that the use of prasugrel plus bivalirudin in primary angioplasty would reduce stent thrombosis and cardiovascular events. METHOD: Consecutive patients with acute ST-segment elevation myocardial infarction who were treated by primary angioplasty within 12 hours of the onset of symptoms received bivalirudin plus clopidogrel (Group A) or bivalirudin plus prasugrel (Group B). We compared the groups using propensity score matching. The combined end-point was cardiac death, thrombosis, acute myocardial infarction, and cerebrovascular accident at 30 days. RESULTS: We assessed 168 patients. The approach was preferentially radial (95.7%). No differences in baseline characteristics were observed between Groups A (n = 70) and B (n = 70). The total mortality and rate of major bleeding complications at 30 days were 0% for both of the groups. The rate of acute and subacute thrombosis was 4.3% in Group A and 0% in Group B (P = 0.08). We observed an increased rate of events in Group A (5.7%) versus Group B (0%) (P = 0.042). CONCLUSIONS: The administration of bivalirudin plus prasugrel in primary percutaneous coronary intervention reduces cardiovascular effects compared to bivalirudin plus clopidogrel without increasing major bleeding complications during the first 30 days following primary angioplasty performed with a preferentially radial approach.

Doble fístula coronaria como causa de angina inestable / Dual coronary artery fistulas as a cause of unstable angina

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Short and long-term benefits of sirolimus-eluting stent in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials.

BACKGROUND: Recent concerns have emerged on the potential higher risk of stent thrombosis after DES implantation, that might be even more pronounced among STEMI patients. The aim of the current study was to perform a meta-analysis to evaluate the benefits and safety of Sirolimus-Eluting Stent (SES) as compared to BMS in patients undergoing primary angioplasty for STEMI. METHODS: The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following keywords were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus. RESULTS: A total of 9 trials were included in the meta-analysis, involving 2,769 patients (1389 or 50.2% randomized to DES and 1,380 or 49.8% randomized to BMS). At 12 months follow-up, SES was associated with a significant reduction in TVR (4.9% vs. 13.6%, p < 0.0001), with a trend in benefits in mortality (2.9% vs. 4.2%, p = 0.08) and reinfarction (3.0% vs. 4.3%, p = 0.06), without any significant difference in stent thrombosis (1.9% vs. 2.5%, p = 0.36). Safety and efficacy of DES were confirmed at 2-3 years follow-up (data available from 4 trials including 569 patients). CONCLUSIONS: This meta-analysis shows that among selected STEMI patients undergoing primary angioplasty, SES as compared to BMS is safe and associated with a significant reduction in TVR at 1 and 2-3 years follow-up.

Sirolimus-eluting stents compared with standard stents in the treatment of patients with primary angioplasty.

BACKGROUND: Sirolimus-eluting stents have been shown to decrease restenosis and reintervention as compared with standard stents. We evaluated the use of sirolimus-eluting stents in primary percutaneous coronary intervention for acute myocardial infarction with ST-segment elevation. METHODS: We randomly assigned 120 patients to compare sirolimus-eluting stents with uncoated stents in primary percutaneous coronary intervention for acute myocardial infarction with ST-segment elevation. The primary end point was composite: death from cardiac causes, recurrent myocardial infarction, or target-lesion revascularization after 360 days. RESULTS: The rate of the primary end point was 6.7% in the sirolimus-eluting stent and 11% in the bare-metal stent group (relative risk 1.75, 95% CI 0.47-6.57, P = .402). The survival free from target-vessel failure showed a higher trend in the sirolimus-eluting stent group than in the bare-metal stent group (0.0% vs 5.7%, P = .064). There was no significant difference between the 2 groups in the rate of death (5% and 3.6%, respectively; P = .736), reinfarction (1.7% and 1.8%, respectively; P = .940), or stent thrombosis (3.4% and 1.8%, respectively; P = .621). CONCLUSIONS: Among selected patients with acute myocardial infarction and ST-segment elevation, the use of sirolimus-eluting stents shows a trend to reduce the rate of target-vessel revascularization in comparison with bare-metal stent.

[Percutaneous treatment of bifurcation lesions by crush T stenting: immediate and medium-term outcomes]. / Tratamiento de las lesiones bifurcadas mediante técnica de crush T stenting: resultados inmediatos y a medio plazo.

INTRODUCTION AND OBJECTIVES: Percutaneous coronary intervention for coronary bifurcations is usually associated with a low success rate, a high rate of complications, and a more frequent need for target lesion revascularization. The aim of this prospective study was to evaluate immediate and medium-term clinical and angiographic outcomes after the application of crush T stenting. METHODS: This approach to bifurcation stenting follows the same steps as modified T stenting. The only difference is that the side branch stent protrudes 3-4 mm into the main vessel from the carina. The aim is to ensure that the circumference of the side branch ostium is covered by the stent strut. RESULTS: Between December 2003 and February 2005, 82 patients were included in the study. The lesion involved the left main coronary artery in 53% of patients, the left anterior descending or diagonal coronary artery in 29%, the circumflex or marginal branch in 11%, and the right coronary artery or the posterior or posterolateral descending branch in 7%. Angiographic and clinical success was obtained in 100% and 96.4% of cases, respectively. Final dilatation was performed using a kissing balloon in 87%. Overall, 100% of patients were followed up clinically for 12 months and 77% were followed up angiographically for a mean of 8.7 (3.3) months. Target lesion revascularization was performed in 9 patients (10.8%). CONCLUSIONS: Treatment of coronary bifurcation lesions using the crush T stenting technique is safe and effective. It reduces both the restenosis rate and the major adverse cardiac event rate at one year.

Tratamiento de las lesiones bifurcadas mediante técnica de crush T stenting: resultados inmediatos y a medio plazo / Percutaneous treatment of bifurcation lesions by crush T stenting: immediate and medium- term outcomes

Introducción y objetivos. El tratamiento percutáneo de las lesiones bifurcadas se asocia con una menor tasa de éxito y una mayor frecuencia de complicaciones y de nueva revascularización de la lesión tratada. El objetivo de este estudio prospectivo fue evaluar los resultados clínicos y angiográficos iniciales y a medio plazo de la técnica de crush T stenting. Métodos. Este método de tratamiento percútaneo de las lesiones bifurcadas con implante de stents coronarios reproduce la técnica T stenting modificada con la diferencia de que el stent de la rama lateral protruye dentro de la rama principal a 3-4 mm de la carina. El propósito es asegurar que el ostium de la rama lateral es cubierto circunferencialmente con la malla de los stents. Resultados. Entre diciembre de 2003 y febrero de 2005 se incluyó a 82 pacientes en este estudio. La lesión afectaba al tronco coronario izquierdo en bifurcación en el 53%, a la arteria descendente anterior/diagonal en el 29%, a la arteria circunfleja/marginal en el 11% y a la coronaria derecha/descendente posterior-posterolateral en el 7%. Éxito angiográfico y clínico se obtuvo en el 100 y el 96,4%, respectivamente. Se realizó posdilatación con doble balón en el 87%. Se obtuvo seguimiento clínico a los 12 meses en el 100% y angiográfico en el 77%. El tiempo medio de seguimiento angiográfico fue 8,7 ± 3,3 meses. Se realizó una nueva revascularización de la lesión tratada en el 10,8%. Conclusiones. El tratamiento de las lesiones bifurcadas con técnica de crush T stenting es segura y efectiva, y presenta una baja tasa de eventos cardiacos mayores y de necesidad de nueva revascularización (AU)

Introduction and objectives. Percutaneous coronary intervention for coronary bifurcations is usually associated with a low success rate, a high rate of complications, and a more frequent need for target lesion revascularization. The aim of this prospective study was to evaluate immediate and medium-term clinical and angiographic outcomes after the application of crush T stenting. Methods. This approach to bifurcation stenting follows the same steps as modified T stenting. The only difference is that the side branch stent protrudes 3-4 mm into the main vessel from the carina. The aim is to ensure that the circumference of the side branch ostium is covered by the stent strut. Results. Between December 2003 and February 2005, 82 patients were included in the study. The lesion involved the left main coronary artery in 53% of patients, the left anterior descending or diagonal coronary artery in 29%, the circumflex or marginal branch in 11%, and the right coronary artery or the posterior or posterolateral descending branch in 7%. Angiographic and clinical success was obtained in 100% and 96.4% of cases, respectively. Final dilatation was performed using a kissing balloon in 87%. Overall, 100% of patients were followed up clinically for 12 months and 77% were followed up angiographically for a mean of 8.7 (3.3) months. Target lesion revascularization was performed in 9 patients (10.8%). Conclusions. Treatment of coronary bifurcation lesions using the crush T stenting technique is safe and effective. It reduces both the restenosis rate and the major adverse cardiac event rate at one year (AU)

[Percutaneous occlusion with coils of coronary artery fistulas in adults]. / Fístulas de arterias coronarias en adultos. Oclusión percutánea mediante coils.

Coronary artery fistulas are one of the most common congenital anomalies of the coronary arteries. Most fistulas are small and of no clinical significance, although larger or multiple fistulas can be symptomatic and produce complications. Early percutaneous occlusion is now always recommended, and surgical closure is restricted to use for multiple or large fistulas. Here we report four cases of coronary fistula draining from the coronary arteries to the pulmonary vascular bed, which were treated with percutaneous occlusion by coils.

Fístulas de arterias coronarias en adultos. Oclusión percutánea mediante coils / Percutaneous occlusion with coils of coronary artery fistulas in adults

La fístula arterial coronaria es una de las anomalías congénitas más frecuentes de las arterias coronarias. Las fístulas coronarias suelen ser pequeñas y sin significación clínica, pero las más grandes pueden causar síntomas y llegar a producir complicaciones. Actualmente, se recomienda siempre su cierre temprano percutáneo, reservando la cirugía para las fístulas múltiples o de gran tamaño. Presentamos 4 casos de fístulas coronarias que drenaban en el territorio vascular pulmonar tratadas mediante oclusión percutánea con coils

Coronary artery fistulas are one of the most common congenital anomalies of the coronary arteries. Most fistulas are small and of no clinical significance, although larger or multiple fistulas can be symptomatic and produce complications. Early percutaneous occlusion is now always recommended, and surgical closure is restricted to use for multiple or large fistulas. Here we report four cases of coronary fistula draining from the coronary arteries to the pulmonary vascular bed, which were treated with percutaneous occlusion by coils

Respuesta: Prevención de las complicaciones vasculares en el intervencionismo coronario. ¿Cambio de acceso o sellado de la vía? / No disponible

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Long-term prognosis of patients having acute myocardial infarction when

Data on the long-term prognosis of acute myocardial infarction (AMI) in young patients are limited. This study investigated long-term survival and risk predictors in a series of 108 consecutive patients

[Transradial approach for percutaneous coronary stenting in the treatment of acute myocardial infarction]. / Vía transradial en el tratamiento percutáneo del infarto agudo de miocardio con stents coronarios.

INTRODUCTION AND OBJECTIVE: Treatment of acute myocardial infarction by percutaneous coronary intervention with stenting leads to excellent immediate clinical results and a good prognosis. The aim of this study was to compare in this selected population the safety and effectiveness of radial artery access versus femoral artery access. PATIENTS AND METHOD: Between May 2001 and June 2003, 162 consecutive patients with acute myocardial infarction < 12 hours treated by percutaneous stenting were included in an observational study. The radial artery approach was used in 103 patients, and the femoral artery approach in the remaining 59 patients. The success of the procedure, incidence of major adverse cardiac events and local puncture complications were compared in patients treated with the radial artery versus the femoral artery approach. RESULTS: Fluoroscopy time (22.4 [15.4] min vs 24.5 [19.5] min), immediate success of the procedure (96.1% vs 94.9%), and the incidence of major adverse cardiac events (6.8% vs 8.5%) did not differ between the two groups. Bleeding complications due to local puncture were present only in the femoral artery access group (0 vs 5 patients; P= .007). CONCLUSIONS: In selected patients with acute myocardial infarction treated with primary stent implantation, the success rate and clinical safety of the radial artery approach are similar to those of the femoral artery approach, but the incidence of local complications, especially bleeding, is significantly lower in the former. Thus the radial artery approach should become the approach of choice in patients at high risk for bleeding complications.