Fatores predisponentes para revascularização angiográfica incompleta em pacientes com intervenção coronária percutânea de múltiplos vasos / Predisposing factors for incomplete angiographic revascularization in patients with multivessel percutaneous coronary intervention

A revascularização miocárdica anatômica completa está associada a um melhor controle dossintomas anginosos e a menores índices de eventos cardíacos maiores tardios. No entanto, em substancial número de pacientes tratados por meio de intervenção coronária percutânea (ICP), não logramos sua obtenção. Assim, nosso objetivo foi avaliar os fatores associados à revascularização miocárdica incompleta (RMI) em casos de ICP multiarterial. Métodos: Estudo de coorte envolvendo 1.049 pacientes revascularizados de forma prospectiva e consecutivapor meio de ICP com tratamento de dois ou mais vasos, entre 2012 e 2014, divididos em dois grupos: RMI(n = 324; 30,9%) e revascularização miocárdica completa (n = 725; 69,1%).Resultados: A RMI foi significativamente associada a faixa etária maior (66,5 anos vs. 64,1 anos; p = 0,003),hipertensão arterial (92,2% vs. 86,0%; p = 0,006), insuficiência renal crônica (36.4% vs. 26.0%; p < 0,001), síndrome coronariana aguda (26,3% vs. 21,0%; p = 0,05), revascularização cirúrgica prévia (16,1% vs. 7,1%;p = 0,001), lesões em enxertos venosos (3,4% vs. 1,0%; p < 0,001) e oclusões crônicas (3,3% vs. 1,4%; p =0,005), bem como a menor acesso a stents farmacológicos (57,8% vs. 64,8%; p = 0,002). Os resultados clínicos hospitalares não diferiram entre os grupos.Conclusões: A RMI ocorreu em cerca de um terço dos casos tratados, tendo sido observada associação significativa, com um perfil clínico de maior risco e com intervenções em lesões alvo comumente associadas com menor sucesso do procedimento. O grau de revascularização não gerou impacto nosresultados clínicos da fase hospitalar...

Complete anatomical myocardial revascularization is associated with better anginacontrol and lower rates of cardiac events. However, in a significant number of patients treated bypercutaneous coronary intervention (PCI), complete revascularization is not achieved. Thus, the aimof this study was to evaluate factors associated with incomplete myocardial revascularization (IMR) in multivessel PCI patients. Methods: This was a cohort study involving 1,049 prospectively and consecutively revascularized patients through PCI with treatment of two or more vessels, between 2012 and 2014, divided into two groups: IMR(n = 324; 30.9%) and complete myocardial revascularization (n = 725; 69.1%). Results: IMR was significantly associated with older age (66.5 years vs. 64.1 years; p = 0.003), arterial hypertension (92.2% vs. 86.0%; p = 0.006), chronic renal failure (36.4 % vs. 26.0%; p < 0.001), acute coronary syndrome (26.3% vs. 21.0%; p = 0.05), previous surgical revascularization (16.1% vs. 7.1 %; p = 0.001), saphenous venous graft lesions (3.4% vs. 1.0%, p < 0.001), and chronic occlusions (3.3% vs. 1.4%, p = 0.005), as well as lower access to drug-eluting stents (57.8% vs. 64.8%; p = 0.002). In-hospital clinical outcomes did not differ between the groups. Conclusions: IMR occurred in approximately one-third of treated cases, and a significant association was observed with a higher-risk clinical profile and with target lesion interventions commonly associated with lower procedure success. The degree of revascularization had no impact on in-hospital clinical outcomes...

Implante transcateter valve-in-valve para disfunção de biopróteses cirúrgicas aórticas / Transcatheter valve-in-valve implantation for surgical aortic bioprosthesis dysfunction

Introdução: Estudos recentes têm demonstrado a eficácia do implante transcateter valve-in-valve para otratamento de disfunção de biopróteses em pacientes de alto risco cirúrgico. Apresentamos nossa experiênciainicial com o implante valve-in-valve.Métodos: Caracterizamos o perfil clínico, ecocardiográfico e do procedimento, e reportamos os resultados de médio prazo de pacientes com disfunção de bioprótese submetidos a implante valve-in-valve em posição aórtica. Resultados: Incluímos sete pacientes do sexo masculino, com idade de 72,6 ± 10,0 anos. O escore STS foi 9,6± 10,5%, e o EuroSCORE logístico foi 22,7 ± 14,7%. Três pacientes apresentavam dupla disfunção; dois tinham insuficiência; e dois exibiam estenose isolada. A via transfemoral foi utilizada em seis casos, e a transapical, em um caso. Os dispositivos implantados incluíram as próteses Sapien XT (n = 5) e CoreValve (n = 2). O sucesso do procedimento foi obtido em seis (85,7%) casos. Após o procedimento, o gradiente médio reduziu-se de 38,2 ± 9,6mmHg para 20,9 ± 5,9 mmHg, e a área valvar elevou-se de 1,2 ± 0,4 cm2 para 1,5 ± 0,5 cm2. Ao final de 1 ano, nãoocorreram óbitos e nem outros desfechos adversos significativos; 80% dos pacientes encontravam-se em classefuncional NYHA I/II. Os gradientes transvalvares e a área valvar permaneceram inalterados nesse período. Conclusões: O procedimento valve-in-valve foi eficaz na maioria dos pacientes de alto risco cirúrgico comdisfunção de bioprótese. Quando realizado em pacientes bem selecionados, resulta em desfechos clínicos e hemodinâmicos satisfatórios.

Background: Recent studies have demonstrated the efficacy of the transcatheter valve-in-valveimplantation for the treatment of bioprosthesis dysfunction in high-risk surgical patients. This study presents the initial experience with valve-in-valve implantation. Methods: Clinical, echocardiographic, and procedural profiles were characterized, and the mid-term results of patients with surgical bioprosthesis dysfunction submitted to valve-in-valve implantation in theaortic position were reported.Results: Seven male patients were included, aged 72.6 ± 10.0 years. The STS score was 9,6 ± 10,5%, andthe logistic EuroSCORE was 22.7 ± 14.7%. Three patients had combined aortic bioprosthesis failure; two had isolated regurgitation; and two had isolated stenosis. The transfemoral access was used in six cases, and the transapical access in one case. Implanted devices included Sapien XT (n = 5) and CoreValve (n = 2) prostheses. Procedural success was achieved in six (85.7%) cases. After the procedure, the mean gradient decreased from 38.2 ± 9.6 mmHg to 20.9 ± 5.9 mmHg, and the valve area increased from 1.2 ±0.4 cm2 to 1.5 ± 0.5 cm2. After 1 year, there were no deaths and no other significant adverse outcomes; 80% of patients were in NYHA functional class I/II. The transvalvular gradients and valve area remained unchanged in this period.

A Randomized Trial of Creatine-kinase Leak After Rosuvastatin in Elective Percutaneous Coronary Intervention (CLEAR-PCI).

OBJECTIVES: To determine the impact of percutaneous coronary intervention (PCI) performed at the same time of the peak concentration of rosuvastatin to reduce periprocedural myocardial infarction (PMI). BACKGROUND: Prior studies suggest that a high dose of statin before PCI reduce periprocedural myocardial infarction. However, there is no information regarding the elective PCI performed at the time of the peak of statin concentration to reduce PMI. METHODS: From 2001 to 2013, at a single center in Brazil we enrolled 544 patients who underwent elective PCI and after exclusions for baseline biases in clinical and angiographic characteristics, yielding 528 patients, we prospectively randomly assigned them to either a high loading dose of Rosuvastatin before PCI (n = 264) or standard treatment (n = 264). After exclusions for biases in procedural characteristics a total of 487 patients underwent to end points analysis. The primary outcome was the incidence of MB fraction of creatine kinase (CK-MB) greater than three times the upper limit of normal. RESULTS: The primary end point occurred in 7.6% in the rosuvastatin and 4.8% in the control group (P = 0.200). There was a higher incidence in elevation of CK-MB than normal baseline in the rosuvastatin (67.1% vs 59.2%, P = 0.701). There was no difference in major adverse event (0% in the rosuvastatin group vs 0.8% in control).

Impacto da Curva de Aprendizado na Seleção de Pacientes e nos Resultados Clínicos do Implante por Cateter de Prótese Aórtica / Impact of Transcatheter Aortic Valve Implantation Learning Curve on Patient Selection and Clinical Outcomes

Introdução: O implante por cateter de prótese aórtica (TAVI, do inglês transcatheter aortic valve implantation) constitui tratamento alternativo para pacientes com estenose aórtica de alto risco cirúrgico ou inoperáveis. Para adquirir competência, o grupo multidisciplinar deve receber treinamento específico e acumular experiência na execução do TAVI. Contudo, sua curva de aprendizado não está bem estabelecida. Nosso objetivo foi analisar o impacto da curva de aprendizado na seleção de pacientes, nos aspectos técnicos e nos resultados clínicos do TAVI. Métodos: Estudo observacional e prospectivo dos primeiros 150 pacientes submetidos a TAVI por via femoral, entre janeiro de 2009 e dezembro de 2013 divididos em tercis (n = 50) de acordo com a data do procedimento. Os desfechos foram definidos conforme os critérios Valve Academic Research Consortium-2 (VARC-2). Resultados: A idade foi de 82,5 ± 6,7 anos, sendo 44% homens e 75% em classe NYHA III/IV. O EuroSCORE (24,2 ± 13% vs. 21,2 ± 10,8% vs. 23,4 ± 14,3%) e o STS Score (5,9 ± 2,9% vs. 6,7 ± 4,3% vs. 5,8 ± 3,1%) foram similares entre os grupos. Observou-se redução gradativa nos tempos do procedimento (107,2 ± 48,1 minutos vs. 90,3 ± 42,2 minutos vs. 76,6 ± 37,7 minutos; p < 0,01) e de fluoroscopia (31,3 ± 9,6 minutos vs. 25,4 ± 8,7 minutos vs. 17,2 ± 6,2 minutos; p = 0,01), e no ...

Background: Transcatheter aortic valve implantation (TAVI) is an alternative treatment for high-risk or inoperable patients with aortic stenosis. The multidisciplinary team must undergo specific training and accumulate experience to achieve optimal results. However, its learning curve is not well established. Our objective was to investigate the impact of learning curve on patient selection, technical aspects and clinical outcomes of TAVI. Methods: Observational, prospective analysis of the first 150 patients undergoing transfemoral TAVI between January 2009 and December 2013. Patients were divided into tertiles (n = 50), according to the procedure date. Outcomes were defined according to Valve Academic Research Consortium-2 (VARC-2) criteria. Results: Mean age was 82.5 ± 6.7 years, 44% were male and 75% were in NYHA class III/IV. EuroS-CORE (24.2 ± 13% vs. 21.2 ± 10.8% vs. 23.4 ± 14.3%) and STS Score (5.9 ± 2.9% vs. 6.7 ± 4.3% vs. 5.8 ± 3.1%) were similar between groups. A gradual decrease was observed in procedure times (107.2 ± 48.1 minutes vs. 90.3 ± 42.2 minutes vs. 76.6 ± 37.7 minutes; p < 0.01), fluoroscopy times (31.3 ± 9,6 minutes vs. 25.4 ± 8.7 minutes vs. 17.2 ± 6.2 minutes; p = 0.01) and contrast volume (145.5 ± 70.9 mL vs. 123.2 ± 87.8 mL vs. 101.1 ± 50 mL; p = 0.01). Mortality decreased gradually (20% vs. 10% vs. 4%; p = 0,047), and lower bleeding and moderate-to-severe aortic regurgitation were ...

Clinical, angiographic, and intravascular ultrasound results of the VestSaync II trial.

AIM: We sought to assess the long term efficacy of the novel VESTAsync™ Eluting Stent (VES) combining a Cro-Co platform with a nanothin-microporous hydroxyapatite surface coating impregnated with a polymer-free low-dose of Sirolimus (55 µg). METHODS: The Vestasync II trial was a randomized (2:1), double-blinded, multicenter comparison of the VES to its platform, the Gen X stent, with microporous hydroxyapatite surface coating without sirolimus. Patients were eligible if they presented de novo lesions in native coronary arteries with 3.0-3.5 mm diameter and ≤ 14 mm in length. Primary endpoint was 8-month in-stent late loss and % of stent obstruction. Lifelong aspirin and 6-month clopidogrel were prescribed to all patients. RESULTS: Seventy-five patients were enrolled (VES = 50 pts). Baseline characteristics included mean age of 58 years and 29% of diabetics. Reference vessel diameter and lesion length were 2.8 ± 0.4 mm and 13.0 ± 2.0 mm, respectively. In-stent late loss (0.39 ± 0.20 vs. 0.74 ± 0.52, P = 0.03) and % of neointima hyperplasia (9.3 ± 6.6% vs. 17.6 ± 9.4%, P = 0.0016) were significantly reduced in the VES cohort. Up to 1 year, there was a single case of myocardial infarction and one target lesion revascularization (TLR) (2%) in the VES group while in the control cohort there were one TLR (4%) and one cardiac death (4%). CONCLUSION: The VestSync II trial is a proof-of-concept study and demonstrates the sustained efficacy of this novel polymer-free sirolimus drug-eluting stents. A larger trial, with more complex lesions, clinical endpoints and longer FU period is warranted. © 2013 Wiley Periodicals, Inc.

Clinical, angiographic, and intravascular ultrasound results of the VestSaync II Trial

We sought to assess the long term efficacy of the novel VESTAsyncTM ElutingStent (VES) combining a Cro-Co platform with a nanothin-microporous hydroxyapatitesurface coating impregnated with a polymer-free low-dose of Sirolimus (55 lg). Methods:The Vestasync II trial was a randomized (2:1), double-blinded, multicenter comparisonof the VES to its platform, the Gen X stent, with microporous hydroxyapatitesurface coating without sirolimus. Patients were eligible if they presented de novolesions in native coronary arteries with 3.0–3.5 mm diameter and 14 mm in length.Primary endpoint was 8-month in-stent late loss and % of stent obstruction. Lifelongaspirin and 6-month clopidogrel were prescribed to all patients. Results: Seventy-fivepatients were enrolled (VES550 pts). Baseline characteristics included mean age of 58years and 29% of diabetics. Reference vessel diameter and lesion length were 2.860.4mm and 13.062.0 mm, respectively. In-stent late loss (0.3960.20 vs. 0.7460.52,P50.03) and % of neointima hyperplasia (9.366.6% vs. 17.669.4%, P50.0016) weresignificantly reduced in the VES cohort. Up to 1 year, there was a single case ofmyocardial infarction and one target lesion revascularization (TLR) (2%) in the VESgroup while in the control cohort there were one TLR (4%) and one cardiac death (4%).Conclusion: The VestSync II trial is a proof-of-concept study and demonstrates thesustained efficacy of this novel polymer-free sirolimus drug-eluting stents. A largertrial, with more complex lesions, clinical endpoints and longer FU period is warranted.

Very long-term follow-up of strut apposition and tissue coverage with Biolimus A9 stents analyzed by optical coherence tomography.

First generation drug-eluting stents (DES) are associated with reduced in-stent restenosis but significant increased risk of very late stent thrombosis (VLST). The absence of polymer in DES systems may reduce the occurrence of VLST. Optic coherence tomography (OCT) has been used for stent analysis as a surrogate safety endpoint. This study aimed to assess the long-term follow up of strut apposition and tissue coverage of BioMatrix DES by OCT. 20 patients undergoing BioMatrix DES (n = 15) or S-Stent BMS (n = 5) implantation were followed for at least 5 years and evaluated by quantitative coronary angiography, intravascular ultrasound, and OCT. The difference between the stent types was evaluated by nonparametric Mann-Whitney U test while categorical variables were evaluated by Fisher exact test. Rates of in-stent late loss were similar between groups [0.40 (0.21;0.77) vs. 0.68 (0.66; 0.82) mm, p = 0.205, for BioMatrix and S-Stent, respectively]. The vessel, stent and lumen volumes did not differ between groups. Patients treated with BioMatrix had significantly less stent obstruction [5.6 (4.4;9.7) vs. 28.6 (24.7;29.0) %, p = 0.001]. OCT analysis of 12 stents (Biomatrix = 9 and S-Stent = 3) demonstrated 126 (8.7 %) uncovered struts in the BioMatrix group compared to 23 (4.0 %) in the S-Stent group (p = 0.297), being the majority of them well apposed (117/126 and 21/23, respectively, p = 0.292). Only 9 (0.6 %) struts in the DES and 2 (0.4 %) struts in the BMS groups were simultaneously uncovered and malapposed (p = 0.924). BioMatrix DES was associated with lower rates of in-stent obstruction, and similar percentage of neointimal coverage on struts and of complete strut apposition.

Very long-term follow-up of strut apposition and tissue coverage with Biolimus A9 stents analyzed by optical coherence tomography

associated with reduced in-stent restenosis but significant

increased risk of very late stent thrombosis (VLST).

The absence of polymer in DES systems may reduce the

occurrence of VLST. Optic coherence tomography (OCT)

has been used for stent analysis as a surrogate safety

endpoint. This study aimed to assess the long-term follow

up of strut apposition and tissue coverage of BioMatrixTM

DES by OCT. 20 patients undergoing BioMatrixTM DES

(n = 15) or S-StentTM BMS (n = 5) implantation were

followed for at least 5 years and evaluated by quantitative

coronary angiography, intravascular ultrasound, and OCT.

The difference between the stent types was evaluated by

variables were evaluated by Fisher exact test. Rates of

BioMatrixTM and S-StentTM, respectively]. The vessel,

stent and lumen volumes did not differ between groups.

Patients treated with BioMatrixTM had significantly less

p = 0.001]. OCT analysis of 12 stents (BiomatrixTM = 9

struts in the BioMatrixTM group compared to 23 (4.0 %)

in the S-StentTM group (p = 0.297), being the majority of

them well apposed (117/126 and 21/23, respectively,

p = 0.292). Only 9 (0.6 %) struts in the DES and 2 (0.4 %)

struts in the BMS groups were simultaneously uncovered

associated with lower rates of in-stent obstruction, and

similar percentage of neointimal coverage on struts and of

Alcohol septal ablation after myomectomy failure solutions for unusual cases.

We report an eight-year-old child presented with classical features of hypertrophic obstructive cardiomyopathy and with New York Heart Association (NYHA) class III symptoms, eight months after myectomy and refractory to medical treatment. Cardiac transplantation was indicated due to the severity of symptoms. But the lymphocyte reaction test showed almost 100% reaction of antibodies, and the surgeons rejected the heart transplantation for fear of hyperacute rejection. Then an alcohol septal ablation (ASA) was proposed, which was successfully performed on August 17, 2005. The post-extrasystolic gradient was reduced from 160 to 60 mm Hg immediately and no other complications were seen. The child is being followed since then and echocardiography changes include a further reduction of septum thickness and gradient (P = 0.001), and important symptoms relieved after 3.5 years of follow up. ASA may be an option to be considered in children with critical hypertrophic obstructive cardiomyopathy in NYHA functional class III/IV, when other methods of treatment failed. © 2010 Wiley-Liss, Inc.

Influência dos sintomas pré-procedimentos na evolução hospitalar e tardia das angioplastias carotídeas com implante de stent e sistemas de proteção cerebral / Influence of symptoms pre-procedure in hospital and late evolution of carotid angioplasty with stent implantation and cerebral protection systems

Introdução: A doença carotídea aterosclerótica (DCA) é responsável por 40 por cento dos acidentes vasculares cerebrais (AVC). Apesar de a intervenção carotídea percutânea (ICP) ser uma alternativa à endarterectomia, ainha há poucos dados disponíveis comparando a ICP em pacientes assintomáticos (PAS) versus sintomáticos (PS). O objetivo desta análise foi avaliar essa questão em um grupo consecutivo de pacientes. Métodos: Foram realizadas 262 ICP em 230 pacientes consecutivos, 61 (26,5 por cento) PAS versus 169 (73,5 por cento) PS. A angioplastia carotídea quantitativa (ACQ) foi realizada pré e pós-procedimento e o seguimento clínico, na fase hospitalar e aos 6 e 12 meses. Resultados: As características demográficas foram similares entre os dois grupos, sendo 31 por cento diabéticos. Obtivemos sucesso primário em 100 por cento dos casos, com ausência de complicações maiores em ambos os grupos. Na análise com ACQ, o diâmetro de estenose foi maior no grupo PAS (83,4 maior ou menos 7,6 por cento vs. 74,9 mais ou menos 12,5 por cento; p menor 0,01), mas o grupo PS apresentou lesões mais longas (18,3 mais ou menos 5,7 por cento vs. 21,7 mais ou menos 7,4 por cento; p menor 0,01). Aos 30 dias não houve diferença na incidência de AVC maior...

Background: Carotid atherosclerotic disease (CAD) is responsible for 40% of strokes. Despite percutaneous carotid intervention (PCI) is an alternative to endarterectomy, there is little data available comparing the PCI in asymptomatic vs. symptomatic patients. The purpose of this analysis was to evaluate this issue in a consecutive group of cases. Methods: 262 PCIs were conducted on 230 consecutive patients, 61 (26.5%) in asymptomatic vs. 169 (73.5%) in symptomatic patients. Quantitative carotid angiography (QCA) was performed before and after the procedure and the clinical follow-up obtained in-hospital and at 6 and 12 months. Results: The demographic characteristics were similar between groups; 31% were diabetics. Primary success was obtained in all cases, with no major complications in both groups. QCA analysis revealed a higher diameter stenosis in asymptomatics (83.4% ± 7.6% vs. 74.9% ± 12.5%; p < 0.01), but symptomatic patients had longer lesions (18.3% ± 5.7% vs. 21.7% ± 7.4%; p < 0.01). At 30 days there was no difference in the incidence of major (1.8% vs. 2.0%; p = 0.45) or minor strokes (0 vs. 1.4%; p = 0.19) for both groups. Between 1 and 12 months there have been no additional strokes. A late target vessel revascularization was observed in symptomatic patients but no neurologic deaths in both groups. Conclusion: PCI is safe and effective, with low incidence of complications at 1 and 12 months. The incidence of death, stroke and target vessel revascularization was similar between groups.

Evolução tardia após intervenção coronária percutânea com stents farmacológicos em pacientes diabéticos do Registro DESIRE (Drug-Eluting Stents in the Real World) / Long-Term results after percutaneous coronary intervention with drug eluting stents in diabetic patients in the DESIRE (Drug-Eluting Stents in the Real World)

Fundamentos: O diabetes melito está relacionado à ocorrência de desfechos desfavoráveis após intervenções coronárias percutâneas. Os stents farmacológicos podem conferir melhor evolução tardia a esse subgrupo de pacientes. O objetivo deste estudo foi avaliar o desempenho desses instrumentais em pacientes diabéticos. Métodos: O DESIRE é um registro unicêntrico, prospectivo, que inclui 2,365 pacientes tratados consecutivamente com stents farmacológicos, entre maio de 2002 e janeiro de 2008. Para a presente análise foram excluídos pacientes com diagnóstico de infarto do miocárdio, aqueles com lesão tratada em ponte de safena e os com período de evolução inferior a 6 meses. Resultados: Assim 1.705 pacientes foram divididos em dois grupos: não-diabéticos (n igual 1.211 pacientes, 71,1 por cento) e diabéticos (n igual 494 pacientes, 28,9 por cento),sendo 109 (6,4 por cento) pacientes em uso de insulina. Dentre os diabéticos havia mais idosos (64,8 mais ou menos 9,8 anos vs. 63,4 mais ou menos11,7 anos; p igual 0,025), mulheres (28,9 por cento vs. 22,5 por cento; p igual 0,005), obesos (35,2 por cento vs. 23,5 por cento; p menor 0,001)...

Background: Diabetes mellitus is related to the occurrence of unfavorable outcomes after percutaneous coronary interventions. Drug-eluting stents can confer a better late evolution to this subgroup. The aim of this study was to assess the performance of these devices in diabetic patients. Methods: The DESIRE is a single-center, prospective registry that included 2,365 consecutive patients treated with drug-eluting stents between May 2002 and January 2008. For the present analysis, patients with a diagnosis of acute myocardial infarction, those with saphenous vein grafts lesions and those within 6 months of the index procedure, were excluded. Results: Therefore, 1,705 patients were divided into two groups: non-diabetics (n = 1,211 P/71.1%) and diabetics (n = 494 P/28.9%), of which 109 P (6.4%) were insulin-dependent. Among the diabetics there was a higher number of older people (64.8 ± 9.8 years old vs. 63.4 ± 11.7 years old; p = 0.025), females (28.9 vs. 22.5%; p = 0.005), patients with obesity (35.2 vs. 23.5%; p < 0.001), hypertension (86.6 vs. 73.7%; p < 0.001), multi-vessel disease (63.4 vs. 54.4%; p = 0.001), small-vessel disease (2.70 ± 0.51 mm vs. 2.75 ± 0.42 mm; p < 0.001) and calcified lesions (32.3 vs. 27.1%; p = 0.009).In the late clinical follow up (2.2 ± 1.1 years), the combined cardiac events occurred more frequently in the diabetic patients (9.8 vs. 7.0%; p = 0.048). The multivariate analysis showed that diabetes mellitus (OR = 1.45; 95% confidence interval 1.0 to 2.1) and the presence of a calcified lesion

Stents farmacológicos no mundo real: impacto de sua disponibilidade no perfil de pacientes tratados por meio de intervenção coronária percutânea em um Hospital Público / Drug-eluting stents in the real world scenario: the impact of their availability in the profile of patients treated percutaneously in a public hospital

Introdução: Pacientes submetidos a intervenção percutânea em hospitais públicos brasileiros não têm acesso aos stents farmacológicos. No início de 2006, participamos de um registro multicêntrico internacional que disponibilizava o uso rotineiro dessas próteses, no cenário do mundo real. Neste artigo, procuramos identificar os perfis clínico, angiográfico e do procedimento de pacientes consecutivamente tratados em períodos subseqüentes de dois meses, de acordo com a disponibilidade desses modelos, visando à identificação de eventuais alterações nesses perfis. Método: Estudo observacional de uma série de 471 pacientes, divididos em dois grupos: A, 229 casos dilatados na vigência da disponibilidade de stents farmacológicos; e B, 242 pacientes subseqüentes tratados da forma usual. Não houve critérios de inclusão/exclusão. Resultados: Stents farmacológicos foram mais implantados no grupo A (44% vs. 2%; p < 0,0001). No que se refere às características de base, observou-se predomínio significante de diabéticos dependentes de insulina em A (8% vs. 3%; p = 0,02), o mesmo ocorrendo com lesões-alvo tipos B2 ou C (73% vs. 57%; p < 0,0001), lesões situadas em bifurcações (15% vs. 9%; p = 0,02) e intervenções multiarteriais (15% vs. 6%; p = 0,003). A angiografia quantitativa identificou os casos de A como portadores de estenoses situadas em vasos de menor calibre (2,4 mm vs. 2,6 mm; p = 0,0004), também exibindo lesões mais longas (14,9 mm vs. 12,7 mm; p = 0,0008). Conclusões: A disponibilidade dos stents farmacológicos gerou alterações no perfil dos casos tratados, que passou a abordar situações mais predispostas à reestenose, como os diabéticos dependentes de insulina, os multiarteriais com lesões de alta complexidade e os portadores de lesões mais longas em vasos de fino calibre.

Introduction: Patients submitted to percutaneous intervention in public hospitals in Brazil have no access to DES. At the beginning of 2006, we participated in an international multicenter registry which made available the routine use of these prosthesis, in a “real world” scenario. In this article, we intend to identify the clinical, angiographical and procedural profiles of the patients, consecutively treated in two-month subsequent periods, according to the availability of these models, with the aim of identifying eventual changes in their profiles. Method: Observational series of 471 patients, divided into two groups: A) 229 cases, treated during a period of availability of DES for routine use; and B) 242 patients subsequently treated as usual (no routine avalilability of DES). There were no inclusion/exclusion criteria. Results: More DES were implanted in group A (44% vs. 2%; p<0.0001). Regarding baseline clinical and angiographic characteristics, a significant predominance of insulin-dependent diabetics was observed in group A (8% vs. 3%; p=0.02), as well as B2 or C lesions (73% vs. 57%; p<0.0001); lesions in bifurcations (15% vs. 9%; p=0.02), and multiarterial interventions (15% vs. 6%; p=0.003). Quantitative angiography identified the A group cases as bearers of stenosis placed in smaller vessels (2.4 mm vs. 2.6 mm; p=0.0004), also exhibiting longer lesions (14.9 mm vs. 12.7 mm; p=0.0008). Conclusions: The availability of DES changed the profile of the patients treated, being more likely situations prone to restenosis, such as insulin dependent diabetics, multiarterial disease, patients presenting complex lesions, longer lesions and smaller target vessels.

Incidência de aposição incompleta persistente e tardia após implante de stents com sirolimus e zotarolimus / Incidence of persistent and late-acquired incomplete stent apposition after sirolimus and zotarolimus-eluting stents

Introdução: Aposição incompleta (AI) é descrita após implante de stents farmacológicos (SF) e pode associar-se à trombose de stents. Em razão de diferentes plataformas, polímeros e fármacos utilizados, diferenças na eficácia e na segurança entre SF também são esperadas. Objetivo: Avaliar a incidência de AI persistente e tardia após implante de stents com sirolimus (SES) e com zotarolimus (ZES) e a evolução dos pacientes que apresentem essa alteração. Método: Análise de 242 pacientes tratados com SF (175 pacientes com SES – Cypher® – e 67 pacientes com ZES – Endeavor™) e submetidos a ultra-sonografia intracoronária após o implante e aos seis meses. Resultados: No grupo tratado com SES, 7 (4%) pacientes apresentaram AI tardia e 12 (6,8%), AI persistente. No grupo tratado com ZES, nenhum caso de AI tardia foi identificado e, em 4 pacientes, observou-se AI após o implante e que desapareceu aos seis meses. Nos pacientes com AI tardia, observou-se aumento evolutivo dos volumes do vaso (de 377,2 ± 148,9 mm3 para 431,9 ± 155,1 mm3; p = 0,51)e da placa (de 206,1 ± 51,5 mm3 para 236,9 ± 68,4 mm3; p = 0,36). O volume de hiperplasia intimal foi maior após ZES (16,6 ± 5,8 mm3 vs. 5,1 ± 5,5 mm3; p < 0,0001). Após nove meses, não ocorreram eventos cardíacos adversos nos pacientes com AI. Conclusão: A incidência de AI tardia foi de 2,9% e observada após SES. A presença de AI não esteve relacionada a eventos adversos a médio prazo.

Background: Incomplete stent apposition (ISA) has been documented after drug-eluting stents (DES) and could be related to stent thrombosis. Because DES differ in metal platform, polymer and pharmacological agent, differences in performance and safety are expected. Objective: We sought to investigate the frequency and clinical consequences of ISA after implantation of sirolimus- (SES) and zotarolimuseluting stents (ZES). Methods: 242 patients (pts) who underwent DES placement (175 pts with Cypher® and 67 pts with EndeavorTM stents) had serial intravascular ultrasound (IVUS) performed (at index procedure and after 6-months). Results: 7 pts (4%) had late-acquired ISA after SES. Another 12 (6.8%) pts treated with SES had persistent ISA. Among pts treated with ZES, none had late ISA and 4 had ISA observed after stent implantation that completely resolved at 6-months. There was an increase in vessel (377.2 ± 148.9 to 431.9 ± 155.1 mm3, p = 0.51) and in plaque volume (206.1 ± 51.53 to 236.91 ± 68.4 mm3, p=0.36) in pts with late ISA. Amount of neointimal hyperplasia was significantly higher in ZES than SES (16.6 ± 5.8 mm3 vs 5.1 ± 5.5 mm3, p < 0.0001). After 9 months, no adverse clinical event was observed in pts with ISA. Conclusion: Overall incidence of IVUS-detected late incomplete DES apposition was 2.9%, all after SES. The presence of ISA was not related to clinical adverse events during mid term follow-up.

Drug-eluting stents vs bare metal stents for the treatment of large coronary vessels.

BACKGROUND: Lately drug-eluting stents (DES) have dramatically reduced restenosis rates and need for repeat revascularization in a wide subset of lesion and patients. However, their benefit for the treatment of large vessels (> 3.0 mm) has yet to be established. OBJECTIVE: We investigated whether DES are superior to bare metal stents (BMS) in terms of clinical outcomes for the treatment of large coronary vessels. METHODS: This study assessed the long-term outcomes (cardiac death, acute myocardial infarction, and need for repeat intervention in the treated vessel) of patients treated with either a DES (Cypher and Taxus) or a BMS of > or = 3.5 mm in diameter. A total of 250 consecutive patients who underwent DES implantation were clinically followed for 1 year and compared to 250 patients who were treated with BMS. Interventions in the setting of acute ST elevation myocardial infarction and treatment of bypass grafts were excluded. RESULTS: Cypher was the DES deployed in 70.8% of cases. Most of the enrolled patients were men (78%) with single vessel disease (65.6%). The left anterior descending artery was the culprit vessel in 34.2% of cases. Bare metal stent and DES cohorts had equivalent interpolated reference vessel diameter (3.19 +/- 0.3 mm for BMS vs 3.18 +/- 0.2 for DES; P = .1). Lesion was significantly longer in the group treated with DES (13.4 +/- 5.1 mm for BMS group vs 14.3 +/- 3.5 for DES; P = .0018). After 1 year of clinical follow-up, 95.2% of patients treated with DES and 91.2% of the patients who received BMS were free of major events (P = .2). A trend toward higher target-lesion revascularization was noticed in the group treated with BMS (4.8% vs 1.6%; P = .07). CONCLUSION: Percutaneous treatment of large coronary vessels carries a low risk of clinical events irrespective of the type of stent used.

Cardiovascular effects of local anesthesia with vasoconstrictor during dental extraction in coronary patients.

OBJECTIVE: To evaluate the occurrence of variables detecting myocardial ischemia during or after dental treatment under anesthesia with vasoconstrictor (epinephrine). METHODS: A total of 54 coronary patients undergoing dental extraction under local anesthesia with or without vasoconstrictor were included. They were divided into two groups (by drawing envelopes): group I (27 patients) using anesthetics with vasoconstrictor, and group II (27 cases) without vasoconstrictor. 24-hour Holter monitoring, Doppler-echocardiogram before and after dental intervention, and determination of biochemical markers (CK-MB mass, CK-MB activity, and troponin T) before and 24 hours after dental extraction were performed in all patients. Heart rate and blood pressure were also measured in the pre, post-anesthesia and post-dental extraction phases. Doppler echocardiography assessed left ventricular segmental contractility and the occasional occurrence of mitral regurgitation. The usual pharmaceutical treatment prescribed by the cardiologist was maintained in all cases. RESULTS: Three patients in group I presented ST-segment depression (1.0 mm) during administration of anesthesia; two other patients in group I had CK-MB mass elevation, and ischemia was not observed in any other case, as assessed by the other methods. No chest pain, arrhythmias, occurrence or worsening of left ventricular segmental hypocontractility or mitral regurgitation were observed in the study. CONCLUSION: Dental extraction performed under anesthesia with 1:100,000 epinephrine does not imply additional ischemic risks, as long as performed with good anesthetic technique and maintenance of the pharmacological treatment prescribed by the cardiologist.

Late incomplete apposition after drug-eluting stent implantation: incidence and potential for adverse clinical outcomes.

AIM: Late-acquired incomplete stent apposition (ISA) has been documented after drug-eluting stent (DES) implantation; however, its clinical role remains controversial. We sought to investigate the incidence and long-term clinical consequences of late ISA after implantation of sirolimus- (SES) or paclitaxel-eluting stent (PES) in a non-selected population. METHODS AND RESULTS: From our database, we analysed 195 consecutive patients who underwent DES placement (175 with SES and 20 with PES) into native artery lesions and had serial intravascular ultrasound studies (IVUS) performed at index procedure and after 6-8 months. They were clinically followed for 29 +/- 15 months (median of 24.3 months, interquartile range 18.1-31.6 months). Late ISA was defined as separation of at least one stent strut from the vessel wall in a segment without a side-branch and where the immediate post-implantation IVUS revealed complete apposition of stent struts. We identified 10 patients (5.1%) with late ISA, three patients after PES, and seven patients after SES implantation. ISA was localized almost exclusively at body of the stents (nine out of 10 cases). Mean ISA volume and length were 44.5 +/- 41.9 mm(3) and 7.4 +/- 11 mm, respectively. There was a marked increase in vessel volume from 416.0 +/- 163.9 mm(3) at baseline to 514.4 +/- 247.9 mm(3) at follow-up (P = 0.001) with no significant change in plaque volume (232.4 +/- 52.7 at baseline and 226.4 +/- 22.3 mm(3) at follow-up, P = 0.3) in patients who presented with late-acquired ISA. During the follow-up period, one patient with SES and one patient with PES who presented late-acquired ISA had late stent thrombosis and acute myocardial infarction. CONCLUSION: Late-acquired ISA was observed in 5.1% of patients after DES implantation and is related to regional vessel positive remodelling. The relationship between late-acquired ISA and long-term adverse outcomes (e.g. stent thrombosis) requires further analysis.

Efeitos cardiovasculares da anestesia local com vasoconstritor durante exodontia em coronariopatas / Cardiovascular effects of local anesthesia with vasoconstrictor during dental extraction in coronary patients

OBJETIVO: Avaliar a ocorrência de variáveis detectoras de isquemia miocárdica, durante ou após o tratamento odontológico, sob anestesia com vasoconstritor (adrenalina). MÉTODOS: Foram incluídos 54 pacientes coronariopatas submetidos a exodontia sob anestesia local com ou sem vasoconstritor, divididos em dois grupos (sorteio por envelope): grupo I, composto por 27 que receberam anestésico com vasoconstritor; e grupo II, composto por 27 que receberam anestésico sem vasoconstritor. Todos os pacientes foram submetidos a monitoração eletrocardiográfica com Holter por 24 horas, a Doppler-ecocardiografia realizada antes e após intervenção odontológica, e a dosagem dos marcadores bioquímicos antes e 24 horas após a exodontia (creatina cinase fração MB [CK-MB] massa, CK-MB atividade e troponina T). A freqüência cardíaca e a pressão arterial nas fases pré-anestesia, pós-anestesia e pós-exodontia também foram aferidas. A Doppler-ecocardiografia teve como objetivo avaliar a contratilidade segmentar do ventrículo esquerdo e a eventual ocorrência de insuficiência mitral. Em todos os casos foi mantido o protocolo farmacológico habitual prescrito pelo cardiologista. RESULTADOS: Três pacientes do grupo I apresentaram depressão do segmento ST (1,0 mm) durante a aplicação da anestesia, dois outros pacientes do mesmo grupo tiveram elevação da CK-MB massa, e em nenhum caso foi verificada presença de isquemia avaliada pelos demais métodos. Não houve registro, neste estudo, de precordialgia, arritmias e ocorrência ou agravamento de hipocontratilidade segmentar do ventrículo esquerdo ou insuficiência mitral. CONCLUSÃO: A exodontia praticada sob uso de anestesia com adrenalina 1:100.000 não implica riscos isquêmicos adicionais quando realizada com boa técnica anestésica e manutenção do tratamento farmacológico prescrito pelo cardiologista.

OBJECTIVE: To evaluate the occurrence of variables detecting myocardial ischemia during or after dental treatment under anesthesia with vasoconstrictor (epinephrine). METHODS: A total of 54 coronary patients undergoing dental extraction under local anesthesia with or without vasoconstrictor were included. They were divided into two groups (by drawing envelopes): group I (27 patients) using anesthetics with vasoconstrictor, and group II (27 cases) without vasoconstrictor. 24-hour Holter monitoring, Doppler-echocardiogram before and after dental intervention, and determination of biochemical markers (CK-MB mass, CK-MB activity, and troponin T) before and 24 hours after dental extraction were performed in all patients. Heart rate and blood pressure were also measured in the pre, post-anesthesia and post-dental extraction phases. Doppler echocardiography assessed left ventricular segmental contractility and the occasional occurrence of mitral regurgitation. The usual pharmaceutical treatment prescribed by the cardiologist was maintained in all cases. RESULTS: Three patients in group I presented ST-segment depression (1.0 mm) during administration of anesthesia; two other patients in group I had CK-MB mass elevation, and ischemia was not observed in any other case, as assessed by the other methods. No chest pain, arrhythmias, occurrence or worsening of left ventricular segmental hypocontractility or mitral regurgitation were observed in the study. CONCLUSION: Dental extraction performed under anesthesia with 1:100,000 epinephrine does not imply additional ischemic risks, as long as performed with good anesthetic technique and maintenance of the pharmacological treatment prescribed by the cardiologist.

Resposta coronária às intervenções intravasculares / Coronary response intravascular interventions

O uso de instrumentais percutâneos par tratamento de obstruções no leito coronariano promove algum grau de dano vascular. A resposta do endotélio a essa agressão possui várias etapas, podendo ocorrer em diferentes proporções, desde o modelo considerado fisiológico de reparo vascular até as formas mais extremas representadas pela resposta neointimal exarcebada ou deficiente que parecem estar relacionadas com duas das principais...

Avaliação tardia de endopróteses coronarianas com sirolimus: comparação da tomografia computadorizada por múltiplos detectores com a angiografia quantitativa e o ultra-som intracoronariano / Late outcome of sirolimus-eluting stents: comparison of multidetector computed tomography with quantitative coronary angiography and intravascular ultrasound

OBJETIVO: Avaliar os resultados da tomografia computadorizada por múltiplos detectores na avaliação dos resultados tardios de pacientes submetidos ao implante de endopróteses com sirolimus. MÉTODOS: Selecionamos 30 pacientes, previamente submetidos ao implante de stents com sirolimus com sucesso e com mais de seis meses de evolução. Todos foram submetidos à angiografia invasiva e ao ultra-som intravascular após a angiotomografia, feita com a injeção de 1,5 ml/kg de peso de meio de contraste iodado. RESULTADOS: A média dos diâmetros proximais de referência foi 3,01 ± 0,31 mm pela tomografia e 3,14 ± 0,31 mm pela angiografia (p = 0,04). Ao eliminarmos a artéria circunflexa da análise, a discrepância entre os dois exames deixou de ser significante -(tomografia= 3,01 ± 0,32 mm, angiografia= 3,10 ± 0,30 mm, p = 0,65). A média dos diâmetros distais de referência foi 2,86 ± 0,30 mm pela tomografia e 2,92 ± 0,32 pela angiografia (p = 0,25). A média do calibre mínimo no interior da endoprótese foi 2,85 ± 0,25 mm pela tomografia e 2,85 ± 0,29 mm angiografia (p = 0,27). A área de secção transversal mínima intra-stent foi 7,19 ± 1,47 mm² pela tomografia e 6,90 ± 1,52 mm² pelo ultra-som intracoronariano (p = 0,36), mas a correlação entre estas medidas era fraca (r= 0,33). CONCLUSÃO: A tomografia possibilita a avaliação qualitativa das endopróteses, a estimativa correta do diâmetro de referência proximal e distal dos vasos-alvo, além do calibre mínimo intra-stent. Sua correlação com as medidas feitas pelo ultra-som intracoronário, porém é menos intensa.

OBJECTIVE: To assess the performance of multidetector computed tomography in determining late clinical outcomes of patients undergoing sirolimus-eluting stent implantation. METHODS: Thirty patients, successfully submitted to sirolimus-eluting stent implantation for more than six months, were selected to participate in the study. All underwent invasive angiography and intravascular ultrasound following CT angiography using iodinated contrast medium at a dose of 1.5 ml/kg. RESULTS: Mean proximal reference diameter was 3.01 ± 0.31 mm by tomography and 3.14 ± 0.31 mm by angiography (p = 0.04). When the left circumflex artery was excluded from the analysis, the difference between both examinations was no longer significant (tomography = 3.01 ± 0.32 mm; angiography = 3.10 ± 0.30 mm, p = 0.65). Mean distal reference diameter was 2.86 ± 0.30 mm by tomography and 2.92 ± 0.32 by angiography (p = 0.25). Mean in-stent minimal lumen diameter was 2.85 ± 0.25 mm by tomography and 2.85 ± 0.29 mm by angiography (p = 0.27). Mean minimal in-stent cross-sectional area was 7.19 ± 1.47 mm² by tomography and 6.90 ± 1.52 mm² by intravascular ultrasound (p = 0.36), but there was only a weak correlation between these measurements (r = 0.33). CONCLUSION: Computed tomography allows the qualitative assessment of sirolimus-eluting stents, accurate estimate of proximal and distal reference diameters of the target vessel, and in-stent minimal lumen diameter. Its correlation with measurements performed using intravascular ultrasound, however, is less strong.

Double balloon pulmonary valvuloplasty: multi-track system versus conventional technique.

OBJECTIVES: To evaluate whether double balloon pulmonary valvuloplasty (DBPV) with the Multi-Track system (MTS) may help to simplify the procedure. BACKGROUND: DBPV is usually required for patients with pulmonary valve stenosis with large annulus. However, it needs two venous accesses and can be technically demanding. METHODS: From 07/03, 20 consecutive patients (19 +/- 10 yrs) with typical pulmonary valve stenosis underwent DBPV using the MTS (G1). The results were compared with those achieved by conventional DBPV performed in a matched historical group of 28 patients (21 +/- 11 yrs; P = NS) (G2). RESULTS: MTS balloons were easily advanced through the skin and inflated across the valve. Similar results were observed in regards to residual gradients (12 +/- 11 vs 14 +/- 10 mm Hg; P = NS) and right ventricular to systemic pressures (0.35 +/- 0.22 vs 0.37 +/- 0.26; P = NS). Procedure and fluoroscopic times were significant lower in G1 (78 +/- 24 vs 126 +/- 28; 15 +/- 12 vs 25 +/- 8 min, respectively; both P < 0.001). There was no major complication. Median follow-up was 1.8 yr for G1 and 5 yr for G2 (P = 0.037). At the last visit, peak instantaneous gradient across the right ventricular outflow tract by echocardiography was a mean 22 +/- 10 mm Hg for G1 and 25 +/- 9 mm Hg for G2 (P = NS). No patient had severe pulmonary insufficiency or required reintervention. CONCLUSIONS: The use of the MTS helped to expedite the procedure providing satisfactory midterm clinical outcomes, similar to those observed with the conventional DBPV technique.