Relation of Macrophage Migration Inhibitory Factor to Pulmonary Hemodynamics and Vascular Structure and Carbamyl-Phosphate Synthetase I Genetic Variations in Pediatric Patients with Congenital Cardiac Shunts.

Macrophage migration inhibitory factor (MIF) plays an important pathophysiological role in pulmonary hypertension (PHT). Previously, we demonstrated that serum MIF is increased in pediatric PHT associated with congenital heart disease (CHD). In the present study, we determined possible associations between MIF levels, hemodynamic and histological parameters, and mitochondrial carbamyl-phosphate synthetase I (CPSI) T1405N polymorphism in a similar population. The asparagine 1405 variant (related to A alleles in the C-to-A transversion) has been shown to be advantageous in pediatric PHT compared to the threonine 1405 variant (C alleles). Forty-one patients were enrolled (aged 2-36 months) and subsequently divided into 2 groups after diagnostic evaluation: the high-pulmonary blood flow (high PBF) group (pulmonary-to-systemic blood flow ratio 2.58 (2.21-3.01), geometric mean with 95% CI) and the high-pulmonary vascular resistance (high PVR) group (pulmonary vascular resistance 6.12 (4.78-7.89) Wood units × m2). Serum MIF was measured using a chemiluminescence assay. The CPSI polymorphism was analyzed by polymerase chain reaction followed by high-resolution melting analysis. Medial hypertrophy of pulmonary arteries was assessed by the histological examination of biopsy specimens. Serum MIF was elevated in patients compared to controls (p = 0.045), particularly in the high-PVR group (n = 16) (p = 0.022) and in subjects with the AC CPSI T1405N genotype (n = 16) compared to those with the CC genotype (n = 25) (p = 0.017). Patients with high-PVR/AC-genotype profile (n = 9) had the highest MIF levels (p = 0.030 compared with the high-PBF/CC-genotype subgroup, n = 18). In high-PVR/AC-genotype patients, the medial wall thickness of intra-acinar pulmonary arteries was directly related to MIF levels (p = 0.033). There were no patients with the relatively rare AA genotype in the study population. Thus, in the advantageous scenario of the asparagine 1405 variant (AC heterozygosity in this study), heightened pulmonary vascular resistance in CHD-PHT is associated with medial hypertrophy of pulmonary arteries where MIF chemokine very likely plays a biological role.

Left Atrial Myxoma Hypervascularized from the Right Coronary Artery: An Interesting Cath Lab Finding.

Primary cardiac tumors are rare and approximately half of them are atrial myxomas. They rarely remain asymptomatic, especially if large. The imaging of a myxoma by contrast dye during coronary angiography is an infrequent sign, which clarifies the vascular supply of the tumor. We report herein an interesting and rare case of a left atrial myxoma hypervascularized from the right coronary artery.

Direct communication between the left circumflex and the right coronary arteries: a very rare coronary anomaly circulation.

Coronary artery anomalies (CAA) are congenital changes in their origin, course, and/or structure. Intercoronary communication (ICC) is a very rare subset with uni- or bidirectional blood flow between two or more coronary arteries. We present the case of a 58-year-old man with an acute coronary syndrome whose coronary angiography incidentally showed a surprising and very rare communication between the right coronary and left circumflex arteries.

Clinical performance of a novel ultrathin strut, low-dose, sirolimus-eluting stent with abluminal-only biodegradable polymeric coating for patients undergoing percutaneous coronary intervention in the daily practice.

BACKGROUND: The present study aimed to evaluate the clinical performance, in the daily practice of a busy catheterization laboratory, of a novel drug-eluting stent (DES) built with an ultra-thin-strut metallic platform, eluting sirolimus at low doses, abluminal coated with biodegradable polymers, and mounted in a low-compliant delivery system. METHODS: Prospective, single-arm study, comprising all consecutive patients undergoing percutaneous coronary intervention (PCI) with the Inspiron™ sirolimus-eluting stent (SES) (Scitech, Aparecida de Goiania, Brazil). The primary endpoint was the occurrence of major adverse cardiac events (MACE) [cardiac death, non-PCI related myocardial infarction (MI), or target vessel revascularization (TVR)]. RESULTS: A total of 470 patients were included, from which 51.3% were diabetics, 33.8% had triple-vessel disease, 15.3% had heart failure, 38.9% had at least one bifurcation treated, 19.8% were treated for a bare metal stent restenosis, and 61.9% had at least one type C lesion; one or more of these features were found in 96.0%. At 300 days, the rate target lesion revascularization was 5.4% and the rate of MACE was 8.1%. The incidence of definite or probable stent thrombosis was 0.4%, with no cases between 30 and 300 days. CONCLUSIONS: The novel stent is associated with excellent short and mid-term clinical outcomes in patients treated with PCI in the daily practice.

Does Ad Hoc Coronary Intervention Reduce Radiation Exposure? – Analysis of 568 Patients / Intervenção Coronariana Ad Hoc Reduz a Exposição Radiológica? - Análise em 568 Pacientes

Background:Advantages and disadvantages of ad hoc percutaneous coronary intervention have been described. However little is known about the radiation exposure of that procedure as compared with the staged intervention.Objective:To compare the radiation dose of the ad hoc percutaneous coronary intervention with that of the staged procedureMethods:The dose-area product and total Kerma were measured, and the doses of the diagnostic and therapeutic procedures were added. In addition, total fluoroscopic time and number of acquisitions were evaluated.Results:A total of 568 consecutive patients were treated with ad hoc percutaneous coronary intervention (n = 320) or staged percutaneous coronary intervention (n = 248). On admission, the ad hoc group had less hypertension (74.1% vs 81.9%; p = 0.035), dyslipidemia (57.8% vs. 67.7%; p = 0.02) and three-vessel disease (38.8% vs. 50.4%; p = 0.015). The ad hoc group was exposed to significantly lower radiation doses, even after baseline characteristic adjustment between both groups. The ad hoc group was exposed to a total dose-area product of 119.7 ± 70.7 Gycm2, while the staged group, to 139.2 ± 75.3 Gycm2 (p < 0.001).Conclusion:Ad hoc percutaneous coronary intervention reduced radiation exposure as compared with diagnostic and therapeutic procedures performed at two separate times.

Fundamento:Uma série de vantagens e desvantagens tem sido descrita para a intervenção coronária percutânea ad hoc, como a realizada ao mesmo tempo que o cateterismo diagnóstico, porém pouco se sabe sobre a exposição radiológica desse procedimento, comparado com a intervenção estadiada, ou seja, em dois momentos.Objetivo:Comparar a dose de radiação utilizada na angioplastia ad hoc com a angioplastia estadiada.Métodos:O produto de dose por área e o Kerma total foram mensurados, somando-se ambas as fases de diagnóstico e terapêutica. Além disso, foram computados o tempo total de fluoroscopia e o número de filmagens.Resultados:Um total de 568 pacientes consecutivos foram tratados com intervenção coronária percutânea ad hoc (n = 320) ou estadiada (n = 248). À admissão, o grupo do ad hoc apresentava menos hipertensão (74,1% vs. 81,9%; p = 0,035), dislipidemia (57,8% vs. 67,7%; p = 0,02) e doença triarterial (38,8% vs. 50,4%; p = 0,015). O grupo ad hoc foi exposto a doses significativamente menores de radiação, mesmo após ajuste para as diferenças basais entre os grupos. O grupo ad hoc foi exposto a uma dose de produto de dose por área total de 119,7 ± 70,7 Gycm2 enquanto que os pacientes estadiados foram expostos a uma dose de 139,2 ± 75,3 Gycm2 (p < 0,001).Conclusão:A intervenção coronária percutânea ad hoc reduziu a exposição radiológica, em comparação com procedimentos diagnósticos e terapêuticos realizados em tempos separados.

Does Ad Hoc Coronary Intervention Reduce Radiation Exposure? - Analysis of 568 Patients.

BACKGROUND: Advantages and disadvantages of ad hoc percutaneous coronary intervention have been described. However little is known about the radiation exposure of that procedure as compared with the staged intervention. OBJECTIVE: To compare the radiation dose of the ad hoc percutaneous coronary intervention with that of the staged procedureMethods:The dose-area product and total Kerma were measured, and the doses of the diagnostic and therapeutic procedures were added. In addition, total fluoroscopic time and number of acquisitions were evaluated. RESULTS: A total of 568 consecutive patients were treated with ad hoc percutaneous coronary intervention (n = 320) or staged percutaneous coronary intervention (n = 248). On admission, the ad hoc group had less hypertension (74.1% vs 81.9%; p = 0.035), dyslipidemia (57.8% vs. 67.7%; p = 0.02) and three-vessel disease (38.8% vs. 50.4%; p = 0.015). The ad hoc group was exposed to significantly lower radiation doses, even after baseline characteristic adjustment between both groups. The ad hoc group was exposed to a total dose-area product of 119.7 ± 70.7 Gycm2, while the staged group, to 139.2 ± 75.3 Gycm2 (p < 0.001). CONCLUSION: Ad hoc percutaneous coronary intervention reduced radiation exposure as compared with diagnostic and therapeutic procedures performed at two separate times.

Type 4 dual left anterior descending artery: a very rare coronary anomaly circulation.

Coronary artery anomalies are congenital changes in their origin, course, and/or structure. They are the second most frequent cause of sudden death in young athletes. Dual LAD artery is a rare coronary anomaly. We present the case of a 44-year-old man with recent onset exertional angina and documented ischemia whose coronary angiogram and computed tomography (CT) showed type 4 dual LAD artery, the rarest and most interesting variant.

Coarctação da Aorta em Crianças com Menos de 25 kg: Tratamento Percutâneo por Punção da Artéria Axilar / Aortic Coarctation in Children Weighing Less than 25 kg: Percutaneous Axillary Artery Approach

Introdução: O tratamento percutâneo da coarctação da aorta é método de escolha em crianças acima de 6 meses de idade e sem hipoplasia do arco aórtico. No entanto, nos pacientes com menos de 25 kg, a via de acesso clássica (femoral) pode representar um problema, principalmente nos implantes de stents, devido ao tamanho dos introdutores. O objetivo deste estudo foi relatar a experiência com a punção da artéria axilar como via de acesso para o tratamento percutâneo de pacientes com coarctação da aorta e peso < 25 kg. Métodos: A punção foi realizada com agulha 21 G, com o braço abduzido em 90º, sendo introduzido fio-guia 0,014 polegada, posicionado na aorta descendente. Um introdutor 5 F pediátrico de 7 cm foi inicialmente utilizado para realização do procedimento, sendo substituído, quando necessário, por um introdutor maior. Após a intervenção, foi realizada compressão hemostática manual. Resultados: Foram tratadas dez crianças, sendo oito com recoarctação póscirúrgica e duas com coactação nativa, com idades de 51,1 ± 30,8 meses e peso de 15,8 ± 5,8 kg. A punção foi realizada em todos os casos sem dificuldade técnica, e a mediana do calibre do introdutor foi de 7 F. Em oito pacientes, foram implantados oito stents e, em dois, foi realizada apenas angioplastia com balão. Houve sucesso técnico em todos os ...

Background: Percutaneous treatment of aortic coarctation is the method of choice in children over 6 months of age and without aortic arch hypoplasia. However in patients less than 25 kg the classical access route (femoral) may pose a problem, especially in cases of stenting, due to the size of the size of the introducers. The objective of this study was to report our experience with the axillary artery approach for the percutaneous treatmentof patients with aortic coarctation weighing less than 25 kg. Methods: The arterial puncture was performed with a 21 G needle, with the arm abducted at 90º, and a 0.014 inch guidewire was positioned in the descending aorta. A 5 F × 7 cm pediatric introducer was initially used for the procedure and whenever required, it was replaced in a larger one. Manual-compression hemostasis was performed after the intervention. Results: Ten children were treated, eight with residual and two with native coarctation, mean age was 51.1 ± 30.8 months and weight 15.8 ± 5.8 kg. Puncture was performed in all cases without technical difficulty and the median introducer size was 7 F. Eight stents were implanted in eight patients and two patients were only treated by balloon angioplasty. Technical success was observed in all patients. After removal of the introducer, there was no permanent pulse loss and one patient had a small local hematoma. Conclusions: In our experience the axillary artery approach for percutaneous ...

Renal artery stenosis predicts coronary artery disease in patients with hypertension.

In hypertensive patients with indication of renal arteriography to investigate renal artery stenosis (RAS) there are no recommendations regarding when to investigate coronary artery disease (CAD). Moreover, the predictors of CAD in patients with RAS are not clear. We aimed to evaluate the frequency and the determinants of CAD in hypertensive patients referred to renal angiography. Eighty-two consecutive patients with high clinical risk suggesting the presence of RAS systematically underwent renal angiography and coronary angiography during the same procedure. Significant arterial stenosis was defined by an obstruction ≥ 70% to both renal and coronary territories. Significant CAD was present in 32/82 (39%) and significant RAS in 32/82 (39%) patients. Both CAD and RAS were present in 25.6% from the 82 patients. Patients with severe CAD were older (63 ± 12 vs. 56 ± 13 years; p = 0.03) and had more angina (41 vs. 16%; p = 0.013) compared to patients without severe CAD. Significant RAS was associated with an increased frequency of severe CAD compared to patients without significant RAS (66% vs. 22%, respectively; p<0.001). Myocardial scintigraphy showed ischemia in 21.8% of the patients with CAD. Binary logistic regression analysis showed that RAS ≥ 70% was independently associated with CAD ≥ 70% (OR: 11.48; 95% CI 3.2-40.2; p<0.001), even in patients without angina (OR: 13.48; 95%CI 2.6-12.1; p<0.001). Even considering a small number of patients with significant RAS, we conclude that in hypertensive patients referred to renal angiography, RAS ≥ 70% may be a strong predictor of severe CAD, independently of angina, and dual investigation should be considered.

Prognóstico tardio em jovens com coronariopatia estável: evolução em 10 anos após intervenção coronária percutânea / Late prognosis in young patients with stable coronary disease: 10-years follow-up of percutaneous coronary intervention

Introdução: Atualmente são ainda desconhecidas as implicaçõesprognósticas tardias da doença arterial coronária (DAC) estável em pacientes jovens. O objetivo deste trabalho foiavaliar o prognóstico de pacientes adultos jovens com diagnóstico de DAC estável, tratados por meio de intervenção coronária percutânea (ICP) e acompanhados por até 10 anos.Métodos: A população do estudo foi constituída por pacientes jovens (idade abaixo do 10o percentil) de um grupo de 1.394 pacientes consecutivos tratados para DAC estável por via percutânea.As características dos pacientes foram coletadas prospectivamente. Após o procedimento foi realizado seguimentoambulatorial, com análise do prontuário hospitalar eletrônico e contato telefônico, quando necessário. O desfecho primário foi a mortalidade geral e o desfecho secundário, a mortalidade cardiovascular. Resultados: Foram selecionados 140 pacientes, com média de idade de 43,7 ± 4 anos (mínimo de 26 anos e máximo de 48 anos), predominantemente do sexo masculino (76,4%). Diabetes melito estava presente em aproximadamenteum quinto dos pacientes e metade apresentava infarto prévio. Os pacientes foram seguidos por uma média de 94,6 ±36,2 meses e a mortalidade geral no seguimento de 10 anos foi de 6%, com mortalidade cardíaca de 5,3%. Todos ospacientes que morreram obtiveram sucesso no procedimento inicial e apenas um dos casos não apresentava infarto prévio. Conclusões: Em nossa prática clínica, pacientes jovens com coronariopatia crônica tratados com ICP mostraram ter bom prognóstico tardio.

Desfechos tardios da intervenção coronária percutânea com stent farmacológico em pontes de veia safena: dados do Registro InCor / Late percutaneous coronary intervention outcomes with drug-eluting stent in saphenous vein grafts: data from the InCor Registry

Introdução: A segurança e a eficácia do uso de stent farmacológico para o tratamento de lesões em ponte de veia safena (PVS) ainda é motivo de controvérsia. Este estudo avaliou a evolução tardia de pacientes com lesões em PVS tratados com stent farmacológico. Métodos: Registro unicêntrico que incluiu todos os pacientes submetidos a intervenção em PVS com stent farmacológico (n = 82), sem restrições clínicas ou angiográficas, no período de 2003 a 2009. Foram avaliadas as taxas de eventos cardíacos adversos maiores (ECAM), óbito, infarto agudo do miocárdio (IAM), revascularização do vaso-alvo (RVA) e trombose de stent. Resultados: A média de idade foi de 67,8 + 10,2 anos, a maioria era do sexo masculino (85,4%), 40,2% eram diabéticos e 52,4% eram portadores de angina estável. Foi utilizado 1,45 + 0,5 stent por paciente, empregando-se ostent CypherTM na maioria (61%) dos casos. O diâmetro dos stents foi de 3,22 + 0,39 mm e o comprimento, de 20,1 +7,3 mm. A taxa de sucesso angiográfico foi de 96,3%. No seguimento de 4,1 anos, a taxa de ECAM foi de 28%, com 6% de óbito, 19,5% de IAM e 18,2% de RVA. Nesse período ocorreram dois casos de trombose de stent definitiva ou provável (2,4%). Conclusões: Os resultados demonstraram, em seguimento muito tardio, altas taxas de ECAM em pacientes com lesões de PVS tratados com stent farmacológico, provavelmente pelo aspecto mais agressivo da doença vascular em enxertos venosos.

Background: The safety and efficacy of drug-eluting stents in the treatment of saphenous vein graft (SVG) lesions remains controversial. This study assessed the late follow-up of patients with SVG lesions treated with drug-eluting stents. Methods: Single center registry including patients undergoingSVG interventions using drug-eluting stents (n = 82), without clinical or angiographic exclusion criteria, from 2003 to 2009. The rates of major adverse cardiac events (MACE), death, acute myocardial infarction (AMI), target vessel revascularization (TVR) and stent thrombosis were evaluated. Results: Mean age was 67.8 + 10.2 years, most of them were male (85.4%), 40.2% were diabetic and 52.4% had stable angina. An average of 1.45 + 0.5 stents per patient were implanted and CypherTM was the stent used in most ofthe cases (61%). Stent diameter was 3.22 + 0.39 mm and stent length was 20.1 + 7.3 mm. Angiographic success rate was 96.3%. In the 4.1-year follow-up, the rate of MACE was 28%, death 6%, AMI 19.5% and TVR 18.2%. Therewere two cases of definitive or probable stent thrombosis (2.4%) within the follow-up period. Conclusions: Longtermfollow-up showed high MACE rates in patients with SVG lesions treated with drug-eluting stents, probably due tothe accelerated atherosclerosis that develops within the grafted vein conduits.

Implante transcateter de prótese valvular aórtica: perfil clínico e evolução de uma série consecutiva de 75 casos do registro conjunto Universidade de Bolonha/Hospital Sírio-Libanês / Transcatheter implantation of aortic valve prosthesis: clinical profile and course of a consecutive series of 75 cases of the Bologna University/Hospital Sírio-Libanês joint registry

Introdução: O implante transcateter de prótese valvular aórtica (ITVA) tem sido utilizado em nosso meio e em diversos países do mundo como alternativa ao tratamento conservador em pacientes com estenose aórtica grave e elevado risco cirúrgico. Objetivou-se descrever o perfil clínico basal e a mortalidade a curto e médio prazos de uma série consecutiva de casos tratados com ITVA em dois centros localizados, respectivamente, na Itália e no Brasil. Métodos: A população de estudo foi composta pelos primeiros 75 pacientes consecutivos com estenose valvar aórtica grave tratados com a prótese Medtronic CoreValve TM Revalving System (MCV – Medtronic, Minneapolis, Estados Unidos). Tipicamente, a indicação para o ITVA foi motivada pelo alto risco cirúrgico. A média de idade era de 82 anos, 55% eram mulheres, um terço apresentava doença pulmonar grave e 95% apresentavam insuficiência cardíaca sintomática. Resultados: Após o ITVA, houve redução significativa do gradiente transvalvar aórtico máximo (basal: 95,8 + 32,3 mmHg; pós-procedimento: 18,5 + 6,1 mmHg) e médio (basal: 45,9 + 16,9 mmHg; pós-procedimento: 10,4 + 5,2 mmHg) (P < 0,01 para ambos). Insuficiência aórtica moderada ou acentuada foi evidenciada em 7% dos casos após ITVA. A taxa de sobrevida global aos 30 dias foi de 91,6% e aos 12 meses, de 79%. Conclusões: O ITVA surge como um método terapêutico de grande relevância para portadores de estenose aórtica de alto risco cirúrgico. As taxas de sobrevida precoce e a médio prazo indicam o benefício potencial do novo procedimento também para pacientes tratados no chamado mundo real.

Background: Transcatheter aortic valve implantation (TAVI) has been used in our country and in several differentcountries worldwide as an alternative to conservative treatment for patients with severe aortic stenosis and high surgicalrisk. This paper aimed at describing the baseline clinical profile and the short and medium-term mortality of a consecutive series of cases treated with TAVI in two centers in Italy and Brazil, respectively. Methods: The study population included the first 75 consecutive patients with severeaortic stenosis treated with the Medtronic CoreValveTM Revalving System (MCV – Medtronic, Minneapolis, USA). Typically, the indication for TAVI was motivated by high surgical risk. Mean age was 82 years, 55% were females, a third had severe lung disease, and 95% had symptomaticheart failure. Results: TAVI was associated with a significant reduction of peak (baseline: 95.8 + 32.3 mmHg; postprocedure: 18.5 + 6.1 mmHg) and mean (baseline: 45.9 + 16.9 mmHg; post-procedure: 10.4 + 5.2 mmHg) transaortic gradient (P < 0.01 for both). Moderate or severe aortic insufficiencywas observed in 7% of the cases. The overall survival rate at 30 days was 91.6% and at 12 months it was 79%.Conclusions: TAVI emerges as an important therapeutic option for high risk patients with aortic stenosis. The short and mediumterm survival rates suggest that the new procedure might beof benefit for patients treated in the real world context.

Evolução clínica de pacientes de alto risco cirúrgico submetidos a intervenção coronária percutânea em tronco da coronária esquerda não-protegido / Clinical outcome in high-surgical-risk patients undergoing percutaneous coronary intervention for unprotected left main coronary artery disease

INTRODUÇÃO: Recentemente, a intervenção coronária percutânea (ICP) em tronco de coronária esquerda (TCE) não-protegido tem se mostrado uma alternativa real à cirurgia de revascularização miocárdica. Os resultados clínicos tardios da ICP nesses pacientes são escassos na literatura, especialmente em nosso meio. Método: Registro de um centro terciário de atenção em cardiologia, que avaliou o seguimento clínico de pacientes com contraindicação à revascularização miocárdica cirúrgica submetidos A ICP em TCE, no período de 2002 a 2009. Nosso objetivo foi avaliar a mortalidade ao final de um ano. Resultados: No total, foram incluídos 77 indivíduos nesta análise, com média de idade de 65,4 +- 13,7 anos, dos quais 59,2 por cento eram do sexo masculino, 25 por cento eram diabéticos e 3,9 por cento eram portadores de insuficiência renal crônica dialítica. Com relação às características angiográficas, 79,6 por cento das lesões eram do tipo B2/C, com envolvimento do óstio em 47,4 por cento e da bifurcação distal em 62,3 por cento. Na maioria dos casos, a indicação de ICP foi emergencial (85,5 por cento) e os stents farmacológicos foram utilizados em 17,5 por cento dos pacientes. Suporte hemodinâmico por meio de balão intra-aórtico foi utilizado em 28,2 por cento da população. Ao final de um ano a probabilidade de sobrevivência...

BACKGROUND: Percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease has proven to be an alternative to coronary artery bypass graft surgery (CABG). However, late clinical results of PCI in these patients are scarce in the literature, especially in our country. METHOD: Data from a tertiary cardiology center registry, which included patients with contraindications to CABG undergoing LMCA PCI, from 2002 to 2009, were analyzed. Our objective was to evaluate the 1-year mortality. RESULTS: A total of 77 subjects were included in this analysis, mean age was 65.4 ± 13.7 years, 59.2% were male, 25% were diabetic, and 3.9% had renal failure requiring dialysis. Regarding the angiographic characteristics, 79.6% of lesions were type B2/C, with involvement of the ostium in 47.4% and distal bifurcation in 62.3%. In most cases PCI was performed as an emergency procedure (85.5%) and drug eluting stents were used in 17.5% of the patients. Hemodynamic support using an intraaortic balloon pump was used in 28.2% of the population. At the end of 1 year the probability of overall survival was 69.7% and almost all of the deaths occurred in the first month of follow-up. CONCLUSION: In this highly selected population with unprotected LMCA disease, including high-surgi

Caracterização e impacto clínico tardio do no-reflow associado a intervenção coronária percutânea primária vs. eletiva / Characterization and late clinical impact of no-reflow associated to primary percutaneous coronary intervention vs. elective percutaneous coronary intervention

INTRODUÇÃO: Apesar dos grandes vasos alcançados pela cardiologia intervencionista, o fenômeno do no-reflow ainda ocorre durante as intervenções coronárias percutâneas (ICP) e está associada a pior prognóstico. O objetivo deste estudo foi caracterizar os perfis clínico, angiográfico e do procedimento de pacientes com no-reflow, além de avaliar seu impacto clínico tardio. Método: Analisamos, no período de janeiro de 2004 a fevereiro de 2009, todos os pacientes submetidos a ICP no Instituto do Coração (InCor), que em qualquer momento da intervenção apresentaram no-reflow, mesmo que transitoriamente. Os pacientes foram divididos em dois grupos: no-reflow de reperfusão (associado a ICP primária) e no-reflow de intervenção (associado a ICP eletiva) A probabilidade de óbito foi estimada pelo método de Kaplan-Meier e a regressçao de Cox foi utilizada para identificar seus preditores. Resultados: Foram avaliados 132 pacientes consecutivos, 81 no grupo no reflow de reperusão e 51 no grupo no-reflow de intervenção. O sucesso do procedimento foi obtido em 83,5 por cento da população total (80,2 por cento vs. 90,2 por cento, respectivamente; P=0,149). A probabilidade de mortalidade tardia foi estimada em 38,6 por cento, sendo maior...

BACKGROUND: Despite major advances in interventional cardiology in recent years, no-reflow is still observed during percutaneous coronary interventions (PCI), and is associated to a worse prognosis. The objective of this study was to characterize the clinical, angiographic and procedural profile of patients with no-reflow as well as assessing its late clinical impact. METHODS: From January 2004 to February 2009, patients undergoing PCI at the Instituto do Coração (InCor), presenting no-reflow at any time during the intervention, were evaluated. Patients were divided into two groups: reperfusion no-reflow (associated to primary PCI) and interventional no-reflow (associated to elective PCI). The probability of death was estimated by the Kaplan-Meier method and Cox regression was used to identify its predictors. RESULTS: One hundred and thirty-two consecutive patients were evaluated, 81 in the reperfusion no-reflow group and 51 in the interventional no-reflow group. Procedural success was observed in 83.5% of the overall population (80.2% vs. 90.2%, respectively; P = 0.149). The long-term probability of death was estimated at 38.6%, and was higher in the reperfusion no-reflow group (55.8% vs. 11.1%; P = 0.005). In the multivariate analysis, only female gender [hazard ratio (HR) 2.5, 95% confidence interval (95% CI) 1.225.14; P = 0.027) and chronic obstructive pulmonary disease (HR 9.35, CI 95% 1.45-60.14; P = 0.027) were independent predictors of mortality, whereas the prior use of statin was a protective factor (HR 0.15, 95% CI 0.05-0.48; P = 0.002). CONCLUSIONS: The no-reflow phenomenon was associated with high procedural failure rates and long-term mortality, especially when associated to primary angioplasty.

Implante transcateter de valva aórtica sem a necessidade de marca-passo definitivo em uma série de casos consecutivos: é possível predizer o risco de bloqueio atrioventricular? / Transcatheter aortic valve implantatation without permanent pacemacker in a series of consecutive cases: is it possible to predict the risk of atrioventricular block?

Introdução: Embora os stents farmacológicos tenham reduzido de forma inconteste o crescimento neointimal e sua consequência clínica direta, a reestenose, questionamentos acerca de sua segurança a longo prazo têm motivado o desenvolvimento de novas tecnologias. A aplicação sistêmica de fármacos antiproliferativos teria o potencial de solucionar o problema da reestenose e ao mesmo tempo amenizar a questão da segurança tardia inerente aos polímeros sintéticos. Recentemente, estudo investigando a administração intravenosa de uma solução de paclitaxel ligado à albumina (ABI-007) produziu efeito discreto na redução da formação de tecido neointimal. Este trabalho teve como objetivo avaliar, por meio da angiografia e do ultrassom intracoronário (USIC) seriados, a efetividade da aplicação intracoronária do ABI-007 na supressão da hiperplasia neointimal após implante de stents não-farmacológicos. Método: Entre novembro de 2006 e maio de 2007, pacientes portadores de lesões coronárias de novo, com extensão < 18 mm, em vasos nativos de 2,5 mm a 3,5 mm de diâmetro, foram submetidos a intervenção coronária percutânea com implante de stents não-farmacológicos, seguida de injeção intracoronária de 70 mg/m² de ABI-007. Avaliação com angiografia e USIC foi programada para todos os pacientes imediatamente após o procedimento e aos seis meses de seguimento. Desfecho primário era a perda luminal tardia (QCA) e o porcentual de obstrução volumétrica gerado pela hiperplasia neointimal (USIC) aos seis meses...

Background: Transcatheter aortic valve implantation (TAVI) is increasingly reported as a valid alternative therapeutic option for patients with aortic valve stenosis with highsurgical risk. Although effective and relatively safe, TAVI is currently associated to the need of permanent pacemaker in 20% to 30% of the cases, with a number of predictors of this complication already described in the literature. Method: We report a series of 8 consecutive patients with aortic stenosis treated with TAVI (Corevalve Revalving, Medtronic Inc., USA). Results: The study population had ahigh surgical risk (on average, STS Score = 22.9% and EuroSCORE = 27.2%). All cases presented at least onehigh-risk predictor for post-procedure high grade atrioventricular block. The interventional procedure was successfully accomplished in all but one patient who presented a cardiac tamponade and in-hospital death. The transaortic pressure gradient was reduced from 91.3 ± 26.9 mmHg to19.4 ± 6.3 mmHg. After hospital discharge, the follow-up time ranged from 4 weeks to 12 months. During follow-up, there were no deaths and none of the patients had a new 2nd or 3rd degree atrioventricular block and permanent pacemaker was not required in any of the cases. Conclusion: Although the lack of a permanent pacemaker in the study population may have occurred by chance, our initial experience suggests that the need of pacemaker following TAVI is not readily predictable with the currently described high-risk predictors.

Prognostic heterogeneity among patients with chronic stable coronary disease: determinants of long-term mortality after treatment with percutaneous intervention.

AIMS: To evaluate the risk and predictors of death in a large population of patients with stable coronary disease treated with percutaneous intervention. METHODS AND RESULTS: The study population comprised 1,276 patients with chronic angina or silent ischaemia who underwent elective coronary angioplasty. Baseline and in-hospital mortality data were prospectively collected for all patients during the index hospitalisation. Post-discharge outcome was assessed at out-patient clinic, by review of the patients' records, or direct phone contact. Deaths were classified as cardiac and non-cardiac. Age, peripheral arterial disease, congestive heart failure with NYHA class >or= III, triple-vessel disease, and procedural success (i.e. angiographic success for all lesions in the absence of peri-procedural infarction) remained as multivariate independent predictors of death. For the entire population 4-year cumulative all-cause and cardiac mortality were respectively 5.4% and 4.1%. Four-year mortality for patients without any multivariate predictor was 2.4%, while for patients with two or more predictors the death rate was 16.3% after four years. CONCLUSIONS: Patients with stable coronary disease undergoing percutaneous treatment have an overall low mortality rate after four years. Nevertheless, stable patients comprise a heterogeneous population in terms of risk profile, ranging from patients at very low risk of late death to individuals with a poor long-term prognosis.

Muito baixo peso ponderal em pacientes tratados com angioplastia coronária: impacto na mortalidade precoce e tardia / Very low ponderal weight in patients treated with coronary angioplasty: impact on early and late mortality

Fundamentos: Pacientes de muito baixo peso tratados com intervenção coronária percutânea têm maior risco de complicações durante a internação. Até o momento, não existem estudos para avaliar o efeito a longo prazo do baixo peso após angioplastia coronária na população brasileira. Método: Um total de 3.687 pacientes foi separado em dois grupos, de acordo com o índice de massa corporal (IMC), calculado como peso (em quilogramas) dividido pela altura (em metros) ao quadrado: grupo baixo peso (IMC ≤ 20 kg/m²; 125 pacientes) e grupo não-baixo peso (IMC > 20 kg/m², 3.562 pacientes). A mortalidade intrahospitalar foi avaliada prospectivamente durante a internação inicial. Após a alta, a ocorrência de óbito foi acessada por meio da revisão dos registros hospitalares e contato telefônico. Resultados: Pacientes com IMC ≤ 20 kg/m² apresentavam peso, altura e IMC médios de 49,4 ± 7,1 kg, 1,62 ± 0,10 m, e 18,7 ± 1,1 kg/m², respectivamente. O peso, a altura e o IMC de pacientes com IMC > 20 kg/m² foram de 74,4 ± 13,8 kg, 1,64 ± 0,09 m, e 27,3 ± 4,3 kg/m², respectivamente (p < 0,01 para todas as características). Pacientes do grupo baixo peso apresentaram mortalidade significativamente maior que pacientes com IMC > 20 kg/m² após 2,5 anos da angioplastia (19,4% vs. 6,9%, respectivamente; hazard ratio [HR]: 2,51, intervalo de confiança de 95% [IC 95%]: 1,61-3,91; p < 0,01). Após o ajuste multivariado para a presença de outros fatores de risco, a presença de IMC ≤ 20 kg/m² persistiu como fator independente associado a aumento da mortalidade (HR: 2,04; IC 95%: 1,28-3,25; p < 0,01)...

Background: Patients with very low weight treated with percutaneous coronary intervention have a greater risk of complications during hospitalization. So far, there have been no studies to evaluate the long-term effect of low weight after coronary angioplasty in the Brazilian population. Methods: A total of 3,687 patients were divided into two groups according to their body mass index (BMI), calculated by dividing the weight in kilograms by the height in metres squared: low-weight group (BMI < 20 kg/m²; 125 patients), and non-low-weight group (BMI > 20 kg/m²; 3,562 patients). The in-hospital mortality was evaluated prospectively during first admission. After discharge, death occurrence was assessed by reviewing hospital records and through telephone contact. Results: Patients with BMI ≤ 20 kg/m² presented weight, height, and BMI averages of 49.4 ± 7.1 kg, 1.62 ± 0.10 m, and 18.7 ± 1.1 kg/m², respectively. The weight, height and BMI of patients with BMI > 20 kg/m² was 74.4 ± 13.8 kg, 1.64 ± 0.09 m, and 27.3 ± 4.3 kg/m², respectively (p < 0.01 for all characteristics). Patients from the low-weight group showed significantly higher mortality than patients with BMI > 20 kg/m² 2.5 years after angioplasty (19.4% vs. 6.9%, respectively; hazard ratio [HR]: 2.51; 95% confidence interval [95% CI]: 1.61-3.91; p < 0.01). After multivariate adjustment for other risk factors, the presence of BMI ≤ 20 kg/m² persisted as an independent factor associated to increased mortality (HR: 2.04; 95% CI: 1.28-3.25; p < 0.01)...

Perfil de segurança dos stents farmacológicos nas síndromes agudas: dados do registro INCOR / Drug eluting stents safety in acute coronary syndromes: the INCOR registry

Fundamentos: Os stents farmacológicos constituem um grande avanço no tratamento da doença coronária. No entanto , seu emprego nas síndromes coronárias agudas tem sido objeto de intensa discussão científica. Método: Entre maio e 2002 e setembro de 2006, 910 pacientes consecutivos foram tratados com implante de pelo menos um stent farmacológico e incluídos na presente análise. Os pacientes foram divididos em dois grupos: grupo estável (635 portadores de angina estável) e grupo agudo (275 pacientes com síndrome coronária aguda sem supra de ST). Analisamos as características clínicas e angiográficas e a ocorrência tardia de eventos adversos. Resultados: As características clínicas foram semelhantes, exceto pela maior frequência de tabagistas nos instáveis e de intervenção percutânea prévia nos estáveis. Após 588 dias (mediana do seguimento), os grupos, estável e agudo, tiveram índices semelhantes de reinfarto (2,8 por cento vs. 5,0 por cento; p = 0,1), revascularização do vaso-alvo (6,0 por cento vs. 7,7 por cento, p = 0,4, óbito (4,5 por cento vs. 6,5 por cento; p= 0,2) e eventos maiores combinados (9,9 por cento, p = 0,4), respectivamente. No entanto, a ocorrência de trombose foi significativamente mais frequênte nos pacientes com quadros coronários agudos...

Background: Drug-eluting stents are a great advance in the treatment of coronary disease. However, their use in patients with acute coronary syndromes has been the subject of intense scientific debate. Methods: 910 consecutive patients treated with at least one drug-eluting stent between May 2002 and September 2006 were enrolled in the present analysis. The patients were assigned to 2 groups according to their clinical condition at the time of admission: 1) Stable group (635 patients with stable angina) and 2) Acute group (275 patients with NSTEMI). We analyzed the clinical and angiographic characteristics as well as the occurrence of late adverse events. Results: The clinical characteristics of the groups were similar, except for the highest incidence of smokers in the acute group and previous percutaneous intervention in the stable group. After 588 days (median follow-up period), the stable and acute groups had similar rates of re-infarction (2.8 vs. 5.0%; p = 0.1), target vessel revascularization (6.0 vs. 7.7%; p = 0.4), death (4.5 vs. 6.5%; p = 0.2) and composite major adverse cardiac events (9.9 vs. 11.9%; p = 0.4), respectively. However, the occurrence of in-stent thrombosis was more frequent in patients with acute coronary diseases (1.4 vs. 4.4%; p = 0.02), mainly due to the occurrence of thrombosis within the first year after implantation (1.1 vs. 4.4%; p = 0.01). Conclusion: Drug-eluting stents have shown a good safety profile in patients with acute coronary syndromes compared to those with chronic coronary disease, despite the higher incidence of late in-stent thrombosis.

Síndrome coronária aguda sem supradesnível de ST de alto risco: a mortalidade intra-hospitalar é proporcionl ao retardo para a intervenção / High risk unstable coronary syndrome: in-hospital mortality is increased with delayed intervention

Fundamentos: Estudos recentes mostram que uma abordagem invasiva rotineira para pacientes com síndrome coronária aguda sem supradesnivelamento do segmento ST diminui eventos em relação a uma abordagem conservadora, mas o tempo ideal para esta abordagem ainda é motivo de debate. Método: No período de maio/2003 a novembro/ 2005, 466 pacientes com infarto agudo do miocárdio, sem supradesnível do segmento ST, foram submetidos à intervenção coronária percutânea, em nossa instituição. Excluímos aqueles pacientes com instabilidade hemodinâmica à admissão. Os pacientes foram divididos em dois grupos, de acordo com o tempo entre a admissão e a realização da angioplastia: 1) Grupo Precoce (intervenção ≤ 6 horas) com 152 pacientes e 2) Grupo Tardio (intervenção >6 horas) com 314 pacientes. Foram analisados os dados do procedimento e a mortalidade intra-hospitalar. Resultados: Os dois grupos foram semelhantes quanto às suas características clínicas, exceto pela maior freqüência de cirurgia coronária prévia no Grupo Tardio. Pacientes no Grupo Precoce foram tratados com uma mediana de 3 horas (intervalo interquartil 2-4 horas) e, no Grupo Tardio, após 23 horas (intervalo interquartil 14-48 horas). Pacientes tratados precocemente apresentaram mortalidade intrahospitalar significativamente menor que os pacientes do Grupo Tardio (0,7 vs. 4,8%; p=0,02). À análise multivariada, idade, insuficiência cardíaca e tempo de tratamento foram identificados como preditores independentes de óbito hospitalar. Conclusão: A realização de angioplastia precoce parece reduzir o risco óbito intra-hospitalar em pacientes com infarto agudo do miocárdio sem supradesnível do segmento ST tratados no dia-a-dia. O impacto clínico da implementação de protocolos de tratamento acelerado para estes pacientes deve ser avaliado no ambiente de estudos randomizados.

Background: Several studies have shown that routine invasive strategies reduce major events compared to a conservative strategy for patients with acute coronary syndrome without ST elevation. However, the optimal time to institute this approach is still debatable. Methods: From May 2003 to November 2005, 466 patients with myocardial infarction without ST elevation, excluding patients with hemodynamic instability, were treated by percutaneous coronary interventions (PCI) in our hospital. Patients were divided in 2 groups according to time from admission to PCI: 1) Early Group (≤6 h) involving 152 patients and 2) Late Group (>6 h) including 314 patients. Procedure data and in-hospital mortality were analyzed. Results: Baseline clinical characteristics were similar in both groups, except for prior CABG that was more frequent in late group. Median time from admission to PCI was 3 hours (interquartile interval: 2-4hours) in the Early Group and 23 hours (interquartile interval: 14-48hours) in the Late Group. In-hospital mortality was significantly reduced in the Early Group (0.7 vs. 4.8%; p=0.02). Age, heart failure and time from admission to PCI were independent predictors of in-hospital mortality by multivariate analysis. Conclusion: Early PCI for myocardial infarction without ST elevation seems to reduce the inhospital mortality in the daily practice. The clinical impac of this accelerated invasive strategy needs to be evaluated in randomized trials.