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.

Transradial occlusion of a large intercostal branch of a left internal mammary artery graft with the novel amplatzer vascular plug 4 using a 4 French diagnostic catheter: treatment of coronary steal phenomenon.

Sidebranches of the left internal mammary artery that are not ligated at the time of coronary artery bypass surgery can cause coronary steal syndrome, resulting in angina. Several isolated case reports have demonstrated successful resolution of this steal syndrome after transcatheter embolization of these branches. Here, we describe successful occlusion of such a sidebranch using an Amplatzer vascular plug via the transradial route with a 4 Fr Judkins Right coronary artery diagnostic catheter.

Ruptured anterior spinal artery aneurysm: a case report.

We present a case of a subarachnoid hemorrhage and vasospasm secondary to a ruptured anterior spinal artery aneurysm associated with a Chiari 1 malformation. To our knowledge this is the first reported spinal artery aneurysm with this association.

Subarachnoid hemorrhage as a presentation of basilar artery dissection.

INTRODUCTION: Subarachnoid hemorrhages caused by intracranial dissections are rare. The management of dissections in these cases not clear. METHODS: Case report. RESULTS: An 82-year-old woman presented with acute drowsiness and vomiting. CT scan demonstrated extensive subarachnoid hemorrhage and hydrocephalus that subsequently required placement of ventriculoperitoneal shunt. Angiography revealed extensive basilar artery dissection and no aneurysms. The dissection did not produce a critical stenosis and, taking into consideration that the patient had a previous occlusion of her distal left vertebral artery, it was decided to manage the patient conservatively. On a 3-month follow-up, the patient was free of recurrent events. CONCLUSION: Basilar artery dissection can present with subarachnoid hemorrhage. No guidelines are available for management of basilar artery dissections and treatment should be tailored to the individual patient.

Thalidomide inhibits the growth and progression of hepatic epithelioid hemangioendothelioma.

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of the liver with an unpredictable malignant potential. Its growth can lead to hepatic failure, extrahepatic metastasis and death. Surgical resection or liver transplantation is the treatment of choice if metastasis is not identified. Several antineoplastic agents have been proposed for cases of nonresectable HEH. We report the case of a 52-year-old patient with HEH metastatic to the lungs who was successfully treated with oral thalidomide therapy.

Neuroimaging of delayed eclampsia. Report of 3 cases and review of the literature.

Computed tomography and magnetic resonance imaging findings consistent with eclampsia were recently encountered in 3 patients who developed severe headache days to weeks after uncomplicated delivery. The neurologic presentation was nonspecific, and pre-eclamptic symptoms were not present, including significant hypertension. Variable expression of pre-eclampsia occurred during the course of their observation. Conventional angiography obtained in 2 patients because of a concern for aneurysm demonstrated central and peripheral vasospasm. Magnetic resonance angiography demonstrated central vasospasm in the third patient.