Clinical, Functional, and Quality of Life Outcomes after Computer Assisted Vacuum Thrombectomy for Pulmonary Embolism: Interim Analysis of the STRIKE-PE Study.

PURPOSE: To report 90-day results from the first interim analysis of the STRIKE-PE study, which is evaluating safety, effectiveness, and functional and quality of life (QoL) outcomes of Computer Assisted Vacuum Thrombectomy (CAVT) with the Indigo Aspiration System for the treatment of acute pulmonary embolism (PE). METHODS: STRIKE-PE is a prospective, international, multicenter study that will enroll 600 adult patients with acute PE of ≤14 days and a right ventricle/left ventricle (RV/LV) ratio of ≥0.9 who receive first-line endovascular treatment with CAVT. Primary endpoints are change in RV/LV ratio and incidence of composite major adverse events (MAEs) within 48 hours. Secondary endpoints include functional and QoL assessments. RESULTS: The first 150 consecutive patients were treated with Lightning 12 CAVT. Mean age was 61.3 years, 54.7% were men, 94.7% presented with intermediate-risk PE, and 5.3% presented with high-risk PE. Median thrombectomy and procedure times were 33.5 minutes and 70 minutes, respectively, resulting in a mean reduction in systolic pulmonary artery pressure of 16.3% (P < .001). Mean RV/LV ratio decreased from 1.39 before thrombectomy to 1.01 at 48 hours, a 25.7% reduction (P < .001). Four patients (2.7%) experienced a composite MAE within 48 hours. At 90-day follow-up, patients exhibited statistically significant improvements in the Borg dyspnea scale and QoL measures, and the NYHA class distribution returned to that reported before the index PE. CONCLUSION: These interim results demonstrate a rapid reduction in RV/LV ratio, achieved with a fast thrombectomy time while maintaining safety. This is accompanied by improvements in 90-day functional and QoL outcomes.

Prospective application of a bleeding and ischemic risks-adjusted antithrombotic protocol in elderly patients revascularized with everolimus-eluting stents: EPIC05-Sierra75 study.

OBJECTIVES: Elderly patients show a higher incidence of ischemic and bleeding events after percutaneous transluminal coronary intervention (PCI). We sought to investigate outcomes in elderly patients treated with antithrombotic strategy guided by bleeding and ischemic risks after revascularization with last generation everolimus-eluting stent (EES). METHODS: Prospective multicenter registry including patients over 75 years revascularized with EES and antithrombotic therapy guided by clinical presentation, PCI complexity and PRECISE DAPT score. Co-primary safety endpoints were: (1) composite of cardiac death, myocardial infarction and stent thrombosis and; (2) bleeding (BARC 2-5). Primary efficacy endpoint was target lesion revascularization. A matched group of patients revascularized with current drug-eluting stents and no such tailored antithrombotic therapy was used as control. RESULTS: Finally, 1064 patients were included in SIERRA-75 cohort, 80.8 ± 4.2 years, 36.6% women, 71% acute coronary syndromes (ACS) and 53.6% complex PCI. Co-primary safety endpoint of major adverse cardiovascular events was met in 6.2%, co-primary safety endpoint of bleeding in 7.8% and primary efficacy endpoint of TKLR in 1.5%. The multivariable adjusted model showed no significant association of the prescribed short/long dual antiplatelet therapy (DAPT) durations with any endpoint suggesting a well tailored therapy. No stent thrombosis reported in the subgroup with 1-3 months DAPT duration. As compared to control group, bleeding BARC 2-5 was significantly lower in SIERRA-75 group (7.4% vs. 10.2%, P = 0.04) as well as the net safety-efficacy endpoint (14.3% vs. 18.5%, P = 0.02). CONCLUSIONS: In elderly population, the application of this risks-adjusted antithrombotic protocol after revascularization with last generation EES seems to be associated with an improved prognosis in terms of ischemic and bleeding outcomes.

Worrisome trends of ST-elevation myocardial infarction during the Covid-19 pandemic: Data from Portuguese centers.

Introduction: During the Covid-19 pandemic there has been a general belief that hospital admissions for non-infectious causes, especially cardiovascular diseases, have fallen. Objectives: To assess the impact of the pandemic on admissions for ST-elevation myocardial infarction (STEMI) during the first pandemic wave. Methods: We performed a multicenter retrospective analysis of consecutive patients presenting with STEMI in two Portuguese hospital centers in two sequential periods - P1 (March 1 to April 30) and P2 (May 1 to June 30). Patient's clinical data and hospital outcomes were compared between the years 2017 to 2019 and 2020 for both periods. Results: During P1 in 2020, a reduction in the number of STEMI patients was observed in comparison with previous years (26.0±4.2 vs. 16.5±4.9 cases per month; p=0.033), as well as an increase in the number of mechanical complications (0.0% vs. 3.0%; p=0.029). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs. 9.1%; p=0.033). An overall trend for longer delays in key timings of STEMI care bundles was noted. Mortality was higher during P1 compared to previous years (1.9% vs. 12.1%; p=0.005). Conclusions: During the first Covid-19 wave fewer patients presented with STEMI at the catheterization laboratory for percutaneous coronary intervention. These patients presented more mechanical complications and higher mortality.

Introdução: Recentemente durante a pandemia por Covid-19 houve uma perceção global de uma diminuição de admissões hospitalares por causas não infeciosas, em particular por doenças cardiovasculares. Objetivos: Avaliar o impacto da pandemia nas admissões por enfarte agudo do miocárdio com supradesnivelamento de ST (STEMI), na primeira onda da pandemia. Métodos: Análise multicêntrica e retrospetiva de doentes consecutivos admitidos em dois hospitais portugueses por STEMI em dois períodos sequenciais - P1 (1 de março a 30 de abril) e P2 (1 de maio a 30 de junho). Foi realizada uma comparação dos dados clínicos e de evolução hospitalar entre 2017 a 2019 e 2020 para os dois períodos. Resultados: No P1 de 2020 observou-se, relativamente a anos prévios, uma redução do número de doentes com STEMI (26,0±4,2 versus 16,5±4,9 casos por mês; p=0,033) e um aumento do número de complicações mecânicas (0,0% versus 3,0%; p=0,029). Os casos de angioplastia após trombólise falhada foram mais frequentes (1,9% versus 9,1%; p=0,033). Observou-se uma tendência global para um maior atraso nos tempos-chave de abordagem de doentes com STEMI. A taxa de mortalidade destes doentes no P1 foi superior comparativamente a anos prévios (1,9% versus 12,1%; p=0,005). Conclusões: Durante a primeira onda da pandemia Covid-19 houve uma redução do número de doentes submetidos a angioplastia coronária por STEMI. Esses apresentaram mais complicações mecânicas e uma maior mortalidade.

Adoption and patterns of use of invasive physiological assessment of coronary artery disease in a large cohort of 40821 real-world procedures over a 12-year period.

INTRODUCTION AND OBJECTIVES: Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame. METHODS: We retrospectively determined the per-procedure prevalence of physiological assessment in 40821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed. RESULTS: Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages <40, 40-55 and >55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology. CONCLUSIONS: Our study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes.

Adoption and patterns of use of invasive physiological assessment of coronary artery disease in a large cohort of 40821 real-world procedures over a 12-year period.

INTRODUCTION AND OBJECTIVES: Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame. METHODS: We retrospectively determined the per-procedure prevalence of physiological assessment in 40821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed. RESULTS: Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages <40, 40-55 and >55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology. CONCLUSIONS: Our study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes.

Non-pharmacological treatment of refractory angina: The coronary sinus reducer, the new kid on the block.

Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients' quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments.

Non-pharmacological treatment of refractory angina: The coronary sinus reducer, the new kid on the block. / Tratamento não farmacológico da angina refratária. Dispositivo de redução do seio coronário, uma nova alternativa terapêutica.

Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients' quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments.

Ten-year survival of patients undergoing coronary angioplasty with first-generation sirolimus-eluting stents and bare-metal stents.

INTRODUCTION: Compared to bare-metal stents (BMS), drug-eluting stents reduce stent restenosis and improve subsequent revascularization rates. The impact on patients' survival has been the subject of debate. OBJECTIVE: To assess the long-term (10-year) survival of patients undergoing percutaneous coronary intervention (PCI) with first-generation sirolimus-eluting stents (SES) in comparison with BMS. METHODS: In a single-center registry, 600 consecutive patients who underwent successful PCI with SES between April 2002 and February 2003 were compared to 594 patients who underwent PCI with BMS between January 2002 and April 2002, just before the introduction of SES. Clinical and procedural data were collected at the time of intervention and 10-year survival status was assessed via the national life status database. RESULTS: All baseline characteristics were similar between groups except for smaller stent diameter (2.84±0.38 vs. 3.19±0.49 mm; p<0.001), greater stent length (18.50±8.2 vs. 15.96±6.10 mm; p<0.001) and higher number of stents per patient (1.95 vs. 1.46, p<0.001) in the SES group. Overall five- and 10-year all-cause mortality was 9.6% (n=110) and 22.7% (n=272), respectively. The adjusted HR for 10-year mortality in patients undergoing PCI with SES was 0.74 (95% CI 0.58-0.94; p=0.013), corresponding to a relative risk reduction of 19.8%. Other than PCI with BMS, older age, chronic kidney disease, chronic obstructive pulmonary disease and lower ejection fraction were independent predictors of 10-year mortality. CONCLUSION: To date, this is the longest follow-up study ever showing a potential survival benefit of first-generation sirolimus-eluting stents versus bare-metal stents, supporting prior observations on their sustained efficacy and safety relative to contemporary BMS.

Neurologic complications after transradial or transfemoral approach for diagnostic and interventional cardiac catheterization: A propensity score analysis of 16,710 cases from a single centre prospective registry.

BACKGROUND AND AIM: Transradial approach (TRA) is being used increasingly as the preferential vascular access site for both diagnostic and interventional procedures. However, concerns have risen about the risk of clinically meaningful neurologic complications. We aimed to assess the association between the risk of stroke/transient ischemic attack (TIA) and the transradial (vs. transfemoral) approach. METHODS AND RESULTS: Data from 16,710 cases included in a single centre prospective registry between January 2006 and November 2012 was analyzed. Radial procedures were considered as those in which the radial access was used either primarily (n = 4,195) or after conversion (n = 36). Potential cases with neurologic events were targeted by cross-referencing patients who underwent both cardiac catheterization and cranial-computed tomography (cranial-CT) during the same admission episode (n = 67). Procedure-related events were defined as a definitive non-CABG related stroke/TIA occurring within 48 hr of the procedure. TRA increased from 0.7% in 2006 to 75% in 2012. Total incidence of stroke/TIA was 0.16% and did not change over the study period (P = 0.26). There was no significant difference in stroke/TIA rates between groups (0.165% vs. 0.160%; P = 1.0). After correction for baseline differences and propensity score matching, TRA was not an independent predictor of stroke/TIA (OR 1.21; 95% CI 0.49-2.98 and 1.3; 95% CI 0.55-3.54, respectively). Results were consistent in pre-specified sub-groups according to age (≥65 y.o. vs. younger), gender, interventional vs. diagnostic and ACS vs. stable. CONCLUSION: Rates of documented stroke/TIA were low. Our observational study suggests that widening the use of the TRA is not associated with an increased risk of clinically relevant procedure-related neurologic complications.

Second-generation versus first-generation drug-eluting stents for the treatment of patients with acute coronary syndromes and obstructive coronary artery disease.

INTRODUCTION AND AIMS: Randomized trials and registries have shown that drug-eluting stents (DES) have an overall better performance than bare-metal stents in patients treated in the setting of both ST-segment and non-ST-segment elevation acute coronary syndromes, mainly by reducing restenosis. Whether or not the use of newer second-generation devices (vs. first-generation DES) differs in these high-risk patients remains to be determined. METHODS AND RESULTS: In a single-centre prospective registry, 3266 patients underwent a percutaneous coronary intervention with at least one DES from January 2003 to December 2009. Of these, 1423 (43.6%) were treated in the setting of an acute coronary syndrome, using either first-generation-only DES [paclitaxel or sirolimus; n=923 (64.9%)] or second-generation-only [zotarolimus or everolimus; n=500 (35.1%)]. The occurrence of death from any cause, nonfatal myocardial infarction or target vessel failure (composite primary endpoint) was compared between these two groups; repeat revascularization of the index stented lesion and definite stent thrombosis [according to the academic research consortium (ARC) definition] were assessed as isolated secondary outcomes. At a median follow-up of 598 days (interquartile range 453-1206), the incidence of death was 10.7% (152), 136 patients (9.6%) had a new myocardial infarction and target vessel failure events occurred in 147 patients (10.3%). Disparity in the follow-up duration was accounted for by considering only the 1-year major adverse cardiac event rate (n=161; 11.3%). After adjustment for baseline characteristics using a Cox proportional hazard model, we could not find a significant difference in the incidence of the composite primary endpoint at 1-year between first-generation (10.8%) and second-generation DES (12.2%) [hazard ratio (HR): 1.1; 95% confidence interval (CI): 0.82-1.57, P=0.463], nor in the occurrence of repeat target lesion revascularization (3.6 vs. 4.4%; HR 1.35; 95% CI 0.77-2.34; P=0.293). In a per patient analysis, at 1 year, ARC-definite ST was documented in 1.0% of patients treated with second-generation DES versus 2.8% in those treated with first-generation DES (corrected HR 0.36; 95% CI 0.14-0.94; P=0.037), owing mostly to a higher difference in late ST. CONCLUSION: Our results suggest that both first-generation and second-generation DES seem to be similarly effective in patients undergoing a percutaneous coronary intervention in the setting of acute coronary syndromes. However, newer second-generation devices may offer potential advantages because of a significantly lower incidence of ARC-definite ST.

Stent thrombosis with second- versus first-generation drug-eluting stents in real-world percutaneous coronary intervention: analysis of 3806 consecutive procedures from a large-volume single-center prospective registry.

BACKGROUND AND AIMS: When compared to their first-generation (1stGEN) counterparts, second-generation (2ndGEN) drug-eluting stents (DESs) have been associated with better clinical outcomes in randomized clinical trials, namely by reducing the rates of stent thrombosis (ST). Our goal was to investigate whether or not the broad use of newer devices would translate into higher safety in a real-world population. For that purpose, we compared the occurrence of definite ST at 12 months between two patient subsets from a large-volume single-center registry, according to the type of DES used. Total mortality was a secondary endpoint. METHODS AND RESULTS: Between January 2003 and December 2010, a total of 3806 patients were submitted to percutaneous coronary intervention (PCI) with only 1stGEN or 2ndGEN DES: 2388 patients (62.7%) were treated with 1stGEN DES only (sirolimus-eluting stent [SES] = 1295 [34.0%]; paclitaxel-eluting stent [PES] = 943 [24.8%]; both stent types were used in 150 patients) and 1418 patients (37.3%) were treated with 2ndGEN DESs only. The total incidence of definite ST (as defined by the Academic Research Consortium) at 12 months was 1.2% (n = 46). After correction for baseline differences between study groups and other variables deemed to influence the occurrence of ST, the use of 1stGEN DES was associated with a significant 2.4-fold increase in the risk of definite ST (95% confidence interval [CI], 1.05-5.42; P=.039) at 12 months; adjusted risk was higher with PES (hazard ratio [HR], 3.6; 95% CI, 1.48-8.70; P=.005) than with SES (HR, 2.3; 95% CI, 0.92-5.65; P=.074). Total mortality (3.7% vs 3.5%) did not differ significantly between groups (adjusted HR, 1.2; 95% CI, 0.81-1.84, P=.348). CONCLUSIONS: Our data suggest that in the real-world setting of contemporary PCI, the unrestricted use of newer 2ndGEN DESs translates into an improvement in PCI safety (relative to 1stGEN DESs), with a significantly lower risk of definite ST at 12 months.

Coronary-subclavian steal syndrome: percutaneous approach.

Coronary subclavian steal syndrome is a rare ischemic cause in patients after myocardial revascularization surgery. Subclavian artery stenosis or compression proximal to the internal mammary artery graft is the underlying cause. The authors present a clinical case of a patient with previous history of non-ST elevation myocardial infarction, triple coronary bypass, and effort angina since the surgery, with a positive ischemic test. Coronary angiography revealed a significant stenosis of the left subclavian artery, proximal to the internal mammary graft.

[Primary PCI in ST-elevation myocardial infarction: mode of referral and time to PCI]. / ICP primária no enfarte de miocárdio com supradesnivelamento do segmento ST: tempo para intervenção e modos de referenciação.

INTRODUCTION: According to the current guidelines for treatment of ST-elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) should be performed within 90 min of first medical contact and total ischemic time should not exceed 120 min. The aim of this study was to analyze compliance with STEMI guidelines in a tertiary PCI center. METHODS: This was a prospective single-center registry of 223 consecutive STEMI patients referred for primary PCI between 2003 and 2007. RESULTS: In this population (mean age 60±12 years, 76% male), median total ischemic time was 4h 30 min (<120 min in 4% of patients). The interval with the best performance was first medical contact to first ECG (median 8 min, <10 min in 59% of patients). The worst intervals were symptom onset to first medical contact (median 104 min, <30 min in 6%) and first ECG to PCI (median 140 min, <90 min in 16%). Shorter total ischemic time was associated with better post-PCI TIMI flow, TIMI frame count and ST-segment resolution (p<0.03). The three most common patient origins were two nearby hospitals (A and B) and the pre-hospital emergency system. The pre-hospital group had shorter total ischemic time than patients from hospitals A or B (2h 45 min vs. 4h 44 min and 6h 40 min, respectively, p<0.05), with shorter door-to-balloon time (89 min vs. 147 min and 146 min, respectively, p<0.05). CONCLUSIONS: In this population, only a small proportion of patients with acute myocardial infarction underwent primary PCI within the recommended time. Patients referred through the pre-hospital emergency system, although a minority, had the best results in terms of early treatment. Compliance with the guidelines translates into better myocardial perfusion achieved through primary PCI.

Evidence-based percutaneous closure of the left atrial appendage in patients with atrial fibrillation.

Atrial fibrillation is the most common cardiac arrhythmia, and its prevalence is increasing. Cardioembolic stroke, most of the times secondary to thrombus formation in the left atrial appendage, is its most feared and life threatening consequence. Oral anticoagulation with vitamin-K-antagonists is currently the most used prophylaxis for stroke in patients with atrial fibrillation; unfortunately, its benefits are limited by a narrow therapeutic window and an increased risk for bleeding, making it often undesired. Percutaneous occlusion of the left atrial appendage is a novel alternative strategy for cardioembolic stroke prophylaxis in patients with atrial fibrillation at a high risk of stroke but with contraindication for long-term oral anticoagulation therapy. At present, several devices have been developed specifically for percutaneous occlusion of the left atrial appendage. Current results show good feasibility and efficacy for these devices, with a high rate of successful implantation, although also associated with the inherent potential periprocedural complications. This work reviews the current state of the art of percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation.

Percutaneous alcohol septal ablation for hypertrophic obstructive cardiomyopathy: technical review and long-term clinical and echocardiographic outcomes.

BACKGROUND: Percutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center. METHODS: This single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4 +/- 12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient > 50 mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness > or = 15 mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25 +/- 38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events. RESULTS: Percutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104 +/- 40 mmHg at baseline to 58 +/- 30 mmHg intraprocedure (p = 0.03) and 35 +/- 26 mmHg at follow-up (p = 0.001); total gradient decrease was 75 +/- 43 mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24 +/- 5 mm to 18 +/- 4 mm, p = 0.02, and from grade 2.4 +/- 0.6 to 1.4 +/- 0.5, p < 0.001, respectively). A tendency for long-term improvement in NYHA functional class (from 2.6 +/- 1.1 to 1.8 +/- 1.4, p = 0.09) was observed. Procedural complications occurred in 6.7% of patients; two deaths and one transient ischemic attack occurred in-hospital, but no long-term clinical events were recorded. CONCLUSIONS: Percutaneous ASA is an effective treatment for symptomatic patients with HOCM, obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement. Despite the occurrence of a significant number of procedural complications, the favorable long-term outcomes underline the potential of ASA as a percutaneous alternative to surgical myectomy.

Percutaneous revascularization strategies in saphenous vein graft lesions: long-term results.

AIMS: Although half of saphenous vein grafts (SVGs) present obstructive atherosclerotic disease 10 years after implantation, controversy remains concerning the ideal treatment. Our aim was to compare percutaneous revascularization (PCI) options in SVG lesions, according to intervention strategy and type of stent. METHODS: A retrospective single-center analysis selected 618 consecutive patients with previous bypass surgery who underwent PCI between 2003 and 2008. Clinical and angiographic parameters were analyzed according to intervention strategy - PCI in SVG vs. native vessel vs. combined approach - and type of stent implanted - drug-eluting (DES) vs. bare-metal (BMS) vs. both. A Cox regressive analysis of event-free survival was performed with regard to the primary outcomes of death, myocardial infarction (MI) and target vessel failure (TVF). RESULTS: During a mean follow-up of 796±548 days the rates of death, MI and TVF were 10.9%, 10.5% and 29.5%, respectively. With regard to intervention strategy (74.4% of PCI performed in native vessels, 17.2% in SVGs and 8.4% combined), no significant differences were seen between groups (death p=0.22, MI p=0.20, TVF p=0.80). The type of stents implanted (DES 83.2%, BMS 10.2%, both 3.2%) also did not influence long-term prognosis (death p=0.09, MI p=0.11, TVF p=0.64). The implantation of DES had a favorable impact on survival (p<0.001) in the subgroup of patients treated in native vessels but not in SVG. CONCLUSIONS: Among patients with SVG lesions, long-term mortality, MI and TVF were not affected by intervention options, except for the favorable impact on survival of DES in patients treated in native vessels.

[NT-proBNP for risk stratification of pulmonary embolism]. / NT-proBNP na estratificação de risco no tromboembolismo pulmonar.

INTRODUCTION: Pulmonary embolism (PE) is an entity with high mortality and morbidity, in which risk stratification for adverse events is essential. N-terminal brain natriuretic peptide (NT-proBNP), a right ventricular dysfunction marker, may be useful in assessing the short-term prognosis of patients with PE. AIMS: To characterize a sample of patients hospitalized with PE according to NT-proBNP level at hospital admission and to assess the impact of this biomarker on short-term evolution. METHODS: We performed a retrospective analysis of consecutive patients admitted with PE over a period of 3.5 years. Based on the median NT-proBNP at hospital admission, patients were divided into two groups (Group 1: NT-proBNP

Post-percutaneous coronary angioplasty atheroembolization--a feared iatrogenic complication.

Atheroembolic disease is a rarely recognized clinical entity. The growing use of antiplatelet and thrombolytic therapy and of invasive cardiovascular procedures in acute coronary syndromes has nevertheless transformed this feared iatrogenic complication into an increasingly frequent diagnosis. The authors review this entity through the case of a 71-year-old man who, fifteen days after undergoing thrombolysis for acute myocardial infarction with ST-segment elevation, followed by elective percutaneous coronary revascularization under triple antiplatelet therapy, came to the emergency department with a clinical setting of mental confusion, gastrointestinal bleeding, oliguria and cutaneous eruptions on the lower limbs; laboratory tests revealed severe azotemia and hyperkalemia. With a diagnostic hypothesis of systemic atheroembolization, a cutaneous lesion biopsy was performed, which confirmed the diagnosis. Supportive treatment led to neurological and cutaneous recovery, but the patient developed chronic renal failure. The pathophysiology, forms of presentation, treatment and prognosis of atheroembolic disease are discussed, highlighting the importance of a high degree of clinical suspicion for diagnosis.