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1.
Front Cardiovasc Med ; 9: 856870, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35402561

RESUMO

Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.

2.
Catheter Cardiovasc Interv ; 99(6): 1848-1856, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35114065

RESUMO

OBJECTIVES:  Investigate the impact of concomitant tricuspid regurgitation (TR) on clinical outcomes during long-term follow-up in patients undergoing percutaneous treatment of mitral regurgitation (MR) with the MitraClip system. BACKGROUND: Patients undergoing mitral repair using the MitraClip frequently present with concomitant TR. It is uncertain how the presence of TR impacts the long-term outcomes of such patients. METHODS: We analyzed consecutive patients with MitraClip implantation from the prospective MitraSwiss registry. Endpoints were all-cause mortality, hospitalization for heart failure, and the composite endpoint of the two. RESULTS: We enrolled 177 patients (mean age 76 ± 9 years, 37% female). Acute procedural success was achieved in 149 (84%). Concomitant moderate or severe TR was present in 31% at baseline and 32% before discharge. After a median follow-up of 1103 days (IQR: 555-1766 days), 70 (40%) of patients had died, and 34 (19%) were hospitalized for heart failure. In multivariable analysis, TR at baseline was associated with an increase in all-cause mortality (HR: 2.34, 95% CI: 1.36-4.03, p < 0.01), hospitalization for heart failure (HR: 3.19, 95% CI: 1.37-7.41, p = 0.01), and the composite endpoint (HR: 2.00, 95% CI: 1.19-3.36, p = 0.01). CONCLUSION: Despite treatment of MR, TR did not improve in most patients. The presence of relevant TR at baseline was associated with reduced survival and higher rates of hospitalization for heart failure. More research is needed to understand the causal role of TR in such patients and to investigate if simultaneous treatment of concomitant TR may improve prognosis in patients undergoing percutaneous treatment of MR.

3.
Front Cardiovasc Med ; 9: 856930, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35498044

RESUMO

Background: The magnesium-based sirolimus-eluting bioresorbable scaffold (Mg-BRS) Magmaris™ showed promising clinical outcomes, including low rates of both the target lesion failure (TLF) and scaffold thrombosis (ScT), in selected study patients. However, insights regarding long-term outcomes (>2 years) in all-comer populations remain scarce. Methods: We analyzed data from a single-center registry, including patients with acute coronary syndrome (ACS) and chronic coronary syndrome (CCS), who had undergone percutaneous coronary intervention (PCI) using the Mg-BRS. The primary outcome comprised the device-oriented composite endpoint (DoCE) representing a hierarchical composite of cardiac death, ScT, target vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (TLR) up to 5 years. Results: In total, 84 patients [mean age 62 ± 11 years and 63 (75%) men] were treated with the Mg-BRS devices between June 2016 and March 2017. Overall, 101 lesions had successfully been treated with the Mg-BRS devices using 1.2 ± 0.4 devices per lesion. Pre- and postdilatation using dedicated devices had been performed in 101 (100%) and 98 (97%) of all the cases, respectively. After a median follow-up time of 62 (61-64) months, 14 (18%) patients had experienced DoCEs, whereas ScT was encountered in 4 (4.9%) patients [early ScTs (<30 days) in three cases and two fatal cases]. In 4 (29%) of DoCE cases, optical coherence tomography confirmed the Mg-BRS collapse and uncontrolled dismantling. Conclusion: In contradiction to earlier studies, we encountered a relatively high rate of DoCEs in an all-comer cohort treated with the Mg-BRS. We even observed scaffold collapse and uncontrolled dismantling. This implicates that this metal-based BRS requires further investigation and may only be used in highly selected cases.

4.
Cardiol J ; 2021 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-34490602

RESUMO

BACKGROUND: Covered coronary stent (CS) implantation is associated with a high risk for in-stent restenosis (ISR) and stent thrombosis (ST). We describe the outcomes after overstenting ("burying") CS using contemporary drug-eluting stents (DES). METHODS: We analyzed short- and long-term outcomes of consecutive patients who had had a CS implanted, which was consecutively covered ("buried") with a third-generation DES. CSs were primarily post-dilated and then covered with a longer DES overlapping the proximal and distal edges of the CS. To ensure optimal stent expansion and appositions, all lesions were post-dilated using adequately sized non-compliant balloons. RESULTS: Between 2015 and 2020, 23 patients (mean age 67 ± 14 years, 74% males) were treated using this novel approach. Reasons for implanting CS included treatment of coronary aneurysms (n = 7; 30%), coronary perforations (n = 13; 57%), and aorto-ostial dissections (n = 3; 13%). All CSs were successfully deployed, and no peri-procedural complications occurred. The median time of follow-up was 24.5 (interquartile range [IQR] 11.7-37.9) months. All patients had a 1-month follow-up (FU) and 19/23 (83%) patients had 12-month FU (FU range 1-60 months). No probable or definite STs occurred, and no cardiovascular deaths were observed. Among patients undergoing angiographic FU (11/23 [48%]), 1/23 showed angiographically significant ISR 6 months post CS implantation. CONCLUSIONS: Burying a coronary CS under a DES appears to be a safe and promising strategy to overcome the limitations of the currently available CS devices, including a relatively high risk for target lesion failure due to ISR and ST.

5.
Open Heart ; 8(2)2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34518287

RESUMO

BACKGROUND: Early studies evaluating the performance of bioresorbable scaffold (BRS) Absorb in in-stent restenosis (ISR) lesions indicated promising short-term to mid-term outcomes. AIMS: To evaluate long-term outcomes (up to 5 years) of patients with ISR treated with the Absorb BRS. METHODS: We did an observational analysis of long-term outcomes of patients treated for ISR using the Absorb BRS (Abbott Vascular, Santa Clara, California, USA) between 2013 and 2016 at the Heart Centre Luzern. The main outcomes included a device-oriented composite endpoint (DOCE), defined as composite of cardiac death, target vessel (TV) myocardial infarction and TV revascularisation, target lesion revascularisation and scaffold thrombosis (ScT). RESULTS: Overall, 118 ISR lesions were treated using totally 131 BRS among 89 patients and 31 (35%) presented with an acute coronary syndrome. The median follow-up time was 66.3 (IQR 52.3-77) months. A DOCE had occurred in 17% at 1 year, 27% at 2 years and 40% at 5 years of all patients treated for ISR using Absorb. ScTs were observed in six (8.4%) of the cohort at 5 years. CONCLUSIONS: Treatment of ISR using the everolimus-eluting BRS Absorb resulted in high rates of DOCE at 5 years. Interestingly, while event rates were low in the first year, there was a massive increase of DOCE between 1 and 5 years after scaffold implantation. With respect to its complexity, involving also a more unpredictable vascular healing process, current and future BRS should be used very restrictively for the treatment of ISR.


Assuntos
Implantes Absorvíveis , Reestenose Coronária/cirurgia , Stents Farmacológicos , Everolimo/farmacologia , Oclusão de Enxerto Vascular/cirurgia , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Idoso , Angiografia Coronária/métodos , Reestenose Coronária/diagnóstico , Reestenose Coronária/etiologia , Feminino , Seguimentos , Oclusão de Enxerto Vascular/complicações , Oclusão de Enxerto Vascular/diagnóstico , Humanos , Imunossupressores/farmacologia , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Tempo , Tecidos Suporte , Resultado do Tratamento
6.
J Am Heart Assoc ; 10(16): e021198, 2021 08 17.
Artigo em Inglês | MEDLINE | ID: mdl-34369166

RESUMO

Background Inflammation plays a pivotal role in coronary artery disease (CAD). The anti-inflammatory drug colchicine seems to reduce ischemic events in patients with CAD. So far there is equipoise about its safety and impact on mortality. Methods and Results To evaluate the utility of colchicine in patients with acute and chronic CAD, we performed a systematic review and meta-analysis. MEDLINE, EMBASE, Cochrane CENTRAL and conference abstracts were searched from January 1975 to October 2020. Randomized trials assessing colchicine compared with placebo/standard therapy in patients with CAD were included. Data were combined using random-effects models. The reliability of the available data was tested using trial sequential analyses . Of 3108 citations, 13 randomized trials (n=13 125) were included. Colchicine versus placebo/standard therapy in patients with CAD reduced risk of myocardial infarction (odds ratio [OR] 0.64; 95% CI, 0.46-0.90; P=0.01; I2 41%) and stroke/transient ischemic attack (OR 0.50; 95% CI, 0.31-0.81; P=0.005; I2 0%). But treatment with colchicine compared with placebo/standard therapy had no influence on all-cause and cardiovascular mortality (OR 0.96; 95% CI, 0.65-1.41; P=0.83; I2 24%; and OR 0.82; 95% CI, 0.55-1.22; P=0.45; I2 0%, respectively). Colchicine increased the risk for gastrointestinal side effects (P<0.001). According to trial sequential analyses, there is only sufficient evidence for a myocardial infarction risk reduction with colchicine. Conclusions Among patients with CAD, colchicine reduces the risk of myocardial infarction and stroke, but has a higher rate of gastrointestinal upset with no influence on all-cause mortality.


Assuntos
Anti-Inflamatórios/uso terapêutico , Colchicina/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Idoso , Anti-Inflamatórios/efeitos adversos , Colchicina/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Resultado do Tratamento
7.
Catheter Cardiovasc Interv ; 98(3): E462-E465, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33847463

RESUMO

OBJECTIVES: Report MANTA-associated vascular complications after implementation of key insights on failure mechanisms. BACKGROUND: The MANTA vascular closure device is utilized to close large-bore arterial access sites. We have previously identified and published the mechanisms and predictors of MANTA-associated vascular complications. We identified three distinct mechanisms leading to MANTA-associated vascular complications, predictors were a common femoral artery (CFA) diameter <6 mm and clinically established peripheral artery disease (PAD). METHODS: We compared 100 consecutive patients of the initial cohort (first n = 100) with consecutive patients in which the key insights acquired in the initial cohort were implemented (second n = 100). RESULTS: The initial cohort (n = 100 patients) had a MANTA-related vascular complication rate of 11% (7% major and 4% minor), and 14% MANTA-related bleeding complications. In a subsequent cohort of n = 100 patients, we applied the abovementioned findings: we did not use the MANTA device if the CFA was <6 mm and in patients with PAD. In addition, femoral puncture was ultrasound guided. This strategy led to a decline in MANTA-related vascular complication rates: 2% (1% major and 1% minor) p = .03, as well as a reduction in MANTA-related bleeding complications to 5% p = .01. To the best of our knowledge, this is the lowest rate of MANTA-related vascular complication reported thus far. CONCLUSIONS: Our strategy achieves low MANTA-related vascular and bleeding complication rates. Careful and critical examination of complications can lead to rapid identification of complication mechanism and its predictors. In turn, rapid implementation of these insights can lead to a decline in complication rates.


Assuntos
Cateterismo Periférico , Dispositivos de Oclusão Vascular , Artéria Femoral/diagnóstico por imagem , Técnicas Hemostáticas , Humanos , Fatores de Tempo , Resultado do Tratamento
8.
Clin Case Rep ; 9(3): 1150-1154, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33768799

RESUMO

Treatment of ST represents a challenge. The presence of large amounts of thrombus combined with stent optimization increase the risk of distal embolization. A two-step strategy of stent implantation and deferred stent optimization might be appropriated. We hereby present three clinical cases of ST successfully treated with a two-step approach.

9.
Am J Case Rep ; 22: e929009, 2021 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-33780431

RESUMO

BACKGROUND It is challenging to distinguish between acute coronary syndrome (ACS) and myocardial injury due to alternative causes (eg myopericarditis, coronary vasospasm, and pulmonary embolism), as they often share similar presentations, especially in young patients. Coronary computerized tomography angiography (CCTA) is increasingly recognized as a fast and safe diagnostic tool for rapid assessment of the coronary anatomy among patients with a low to intermediate cardiovascular risk profile and/or atypical chest pain. However, its utility among patients with possible ACS is still debated. CASE REPORT A 36-year-old man presented to our institution with intermittent pleuritic chest pain and malaise over the preceding 7 days. He was a smoker and his father had ACS at the age of 45 years. The patient had unspecific electrocardiographic changes and elevated troponin values. The initial transthoracic echocardiogram indicated a normal ejection fraction without any wall motion abnormalities. Presuming a very low chance of coronary artery disease due to his age and atypical symptoms, we ordered a CCTA, which identified a thrombotic lesion in the right coronary artery (RCA). An invasive coronary angiography, including an optical coherence tomography, confirmed the presence of a thrombotic lesion located at the level of the proximal RCA, which was consequently treated with 1 drug-eluting stent. CONCLUSIONS Physicians should always eliminate underlying coronary artery disease among patients with unclear myocardial injury, irrespective of a patient's presentation, age, and estimated cardiovascular risk. In this context, CCTA represents a safe and simple tool to rapidly assess the coronary anatomy, especially in younger patients.


Assuntos
Síndrome Coronariana Aguda , Stents Farmacológicos , Síndrome Coronariana Aguda/diagnóstico por imagem , Adulto , Dor no Peito/etiologia , Angiografia Coronária , Humanos , Masculino , Pessoa de Meia-Idade , Troponina
10.
Heart ; 107(21): 1739-1747, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-33504513

RESUMO

OBJECTIVE: Approximately 10% of patients with myocardial infarction (MI) have no obstructive coronary artery disease. The prognosis and role of intensified antiplatelet therapy in those patients were evaluated. METHODS: We analysed data from the Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events-Seventh Organisation to Assess Strategies in Ischaemic Symptoms trial randomising patients with ACS referred for early intervention to receive either double-dose (600 mg, day 1; 150 mg, days 2-7; then 75 mg/day) or standard-dose (300 mg, day 1; then 75 mg/day) clopidogrel. Outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) versus those with obstructive coronary artery disease (CAD) and their relation to standard-dose versus double-dose clopidogrel were evaluated. The primary outcome was cardiovascular (CV) death, MI or stroke at 30 days. RESULTS: We included 23 783 patients with MI and 1599 (6.7%) with MINOCA. Patients with MINOCA were younger, presented more frequently with non-ST-segment elevation MI and had fewer comorbidities. All-cause mortality (0.6% vs 2.3%, p=0.005), CV mortality (0.6% vs 2.2%, p=0.006), repeat MI (0.5% vs 2.3%, p=0.001) and major bleeding (0.6% vs 2.4%, p<0.0001) were lower among patients with MINOCA than among those with obstructive CAD. Among patients with MINOCA, 2.1% of patients in the double-dose clopidogrel group and 0.6% in the standard-dose group experienced a primary outcome (HR 3.57, 95% CI 1.31 to 9.76), whereas in those with obstructive CAD, rates were 4.3% and 4.7%, respectively (HR 0.91, 95% CI 0.80 to 1.03; p value for interaction=0.011). CONCLUSIONS: Patients with MINOCA are at lower risk of recurrent CV events compared with patients with MI with obstructive CAD. Compared with a standard clopidogrel-based dual antiplatelet therapy (DAPT) regimen, an intensified dosing strategy appears to offer no additional benefit with a signal of possible harm. Further randomised trials evaluating the effects of potent DAPT in patients with MINOCA are warranted. TRIAL REGISTRATION NUMBER: NCT00335452.


Assuntos
Clopidogrel/administração & dosagem , Circulação Coronária/efeitos dos fármacos , Vasos Coronários/fisiopatologia , Sistema de Registros , Angiografia Coronária/métodos , Vasos Coronários/diagnóstico por imagem , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , /fisiopatologia , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/administração & dosagem , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
11.
CJC Open ; 3(1): 101-108, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33458636

RESUMO

BACKGROUND: Coronary microvascular dysfunction (CMD) is a common cause of angina and exercise intolerance in patients without obstructive coronary artery disease. The efficacy of ranolazine, a late sodium channel blocker, in patients with symptomatic obstructive coronary artery disease is well established. To evaluate the efficacy of ranolazine in CMD, we performed a systematic review and meta-analysis of randomized studies. METHODS: MEDLINE, EMBASE, Cochrane CENTRAL, and conference abstracts were searched from January 1975 to March 2020. Randomized trials evaluating ranolazine in patients with CMD were screened. Two reviewers independently extracted data and assessed study quality. End points of interest included a change in angina measured by the Seattle Angina Questionnaire (SAQ), coronary flow reserve (CFR), and clinical outcomes. Data were combined using random-effects models. RESULTS: Of 836 citations, 6 randomized studies (318 patients) were included. Median follow-up was 4 weeks. When pooling the 6 trials analyzing ranolazine, we found that patients treated with ranolazine had a higher SAQ value regarding physical functioning (mean difference, 6.42; 95% confidence interval [CI], 2.41; 10.42) quality of life (10.07; 95% CI, 3.4; 16.74), and angina stability (20.14; 95% CI, 10.12; 30.17), as well as improved CFR (0.27; 95% CI, 0.09; 0.45) compared with placebo/control therapy. A high heterogeneity was observed (range I 2, 30%-84%). CONCLUSIONS: In CMD, ranolazine may be associated with improvements in CFR and some of the SAQ domains, including angina stability, physical functioning, and quality of life. However, it does not seem to beneficially impact angina frequency and treatment satisfaction. It is also unknown if it improves prognosis of afflicted patients.


CONTEXTE: La dysfonction microvasculaire coronaire (DMC) est une cause courante d'angine et d'intolérance à l'effort chez les patients sans coronaropathie obstructive. L'efficacité de la ranolazine, un bloqueur des canaux sodiques tardifs, chez les patients atteints d'une coronaropathie obstructive symptomatique est bien établie. Pour évaluer l'efficacité de la ranolazine dans le traitement de la DMC, nous avons effectué une revue systématique et méta-analyse d'études à répartition aléatoire. MÉTHODOLOGIE: MEDLINE, EMBASE, Cochrane CENTRAL et les résumés de congrès ont fait l'objet d'une recherche pour la période allant de janvier 1975 à mars 2020. Les essais à répartition aléatoire sur l'emploi de la ranolazine chez des patients atteints de DMC ont été criblés. Deux examinateurs ont, de manière indépendante, extrait les données et évalué la qualité des études. Les paramètres d'intérêt étaient une variation de l'angine mesurée à l'aide du questionnaire SAQ (Seattle Angina Questionnaire), la réserve coronaire et les issues cliniques. Les données ont été combinées avec des modèles à effets aléatoires. RÉSULTATS: Parmi 836 références, six études à répartition aléatoire (318 patients) ont été retenues. La durée médiane de suivi était de quatre semaines. Après avoir regroupé les données des six essais sur la ranolazine, nous avons constaté que les patients traités par la ranolazine avaient un score SAQ plus élevé en ce qui a trait au fonctionnement physique (différence moyenne : 6,42; intervalle de confiance [IC] à 95 % : 2,41 à 10,42), à la qualité de vie (10,07; IC à 95 % : 3,4 à 16,74) et à la stabilité de l'angine (20,14; IC à 95 % : 10,12 à 30,17), de même qu'une réserve coronaire améliorée (0,27; IC à 95 % : 0,09 à 0,45) comparativement aux patients ayant reçu un placebo/traitement témoin. Une forte hétérogénéité a été observée (plage des I 2 : 30 à 84 %). CONCLUSIONS: Dans les cas de DMC, la ranolazine est associée à des améliorations de la réserve coronaire et de certains des domaines du questionnaire SAQ, dont la stabilité de l'angine, le fonctionnement physique et la qualité de vie. Toutefois, elle ne semble pas avoir d'effet bénéfique sur la fréquence de l'angine et la satisfaction à l'égard du traitement. On ne sait pas non plus si elle améliore le pronostic des patients touchés.

12.
EuroIntervention ; 17(6): 481-488, 2021 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-33258774

RESUMO

BACKGROUND: The comparative efficacy of balloon-based techniques to prepare severely calcified coronary lesions before stenting remains poorly studied. AIMS: We sought to compare stent expansion following preparation of severely calcified coronary lesions with either a super high-pressure balloon or a scoring balloon. METHODS: In this randomised, open-label trial, patients with severely calcified coronary lesions were enrolled at five centres in Germany and Switzerland. After unsuccessful lesion preparation with a standard non-compliant balloon (<30% reduction of baseline diameter stenosis), participants were randomised to predilation with either a super high-pressure balloon or a scoring balloon before drug-eluting stent (DES) implantation. The primary endpoint of the study was stent expansion index as assessed by optical coherence tomography (OCT). The key secondary endpoints included angiographic, strategy and procedural success. RESULTS: OCT data after DES implantation were available for 70 out of 74 patients (94.6%) enrolled. Lesion preparation with a super high-pressure balloon versus a scoring balloon led to a comparable stent expansion index (0.72±0.12 vs 0.68±0.13; p=0.22). Compared with the scoring balloon, the super high-pressure balloon increased the minimum lumen diameter (2.83±0.34 mm vs 2.65±0.36 mm; p=0.03) and reduced the diameter stenosis (11.6±4.8% vs 14.4±5.6%; p=0.02) without difference in terms of angiographic success (100% vs 97.3%; p>0.99). Strategy success (91.9% vs 83.8%; p=0.48) and procedural success (100% vs 89.2%; p=0.12) were numerically more frequent with the super high-pressure balloon versus the scoring balloon. CONCLUSIONS: In patients with severely calcified coronary artery lesions, preparation with a super high-pressure balloon versus a scoring balloon was associated with comparable stent expansion on intravascular imaging and a trend towards improved angiographic performance. Visual summary. A ComparIson of Strategies to PrepAre SeveRely CALCified Coronary Lesions: the ISAR-CALC randomised trial.


Assuntos
Angioplastia Coronária com Balão , Doença da Artéria Coronariana , Reestenose Coronária , Stents Farmacológicos , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Humanos , Stents , Resultado do Tratamento
13.
Open Heart ; 7(2)2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33243930

RESUMO

OBJECTIVES: Report predictors and the natural course of paravalvular leak (PVL) following implantation of the ACURATE neo transcatheter heart valve (THV). BACKGROUND: Understanding the mechanisms of PVL may help to improve patient selection, patient outcomes and the design of next-generation THVs. METHODS: A total of 30 patients (mean age 81±5 years, 47% women) undergoing transcatheter aortic valve replacement with the ACURATE neo were enrolled in the PREDICT PVL study. The effective regurgitant orifice area (EROA, in mm2) of PVL was assessed by transthoracic and transoesophageal echocardiography before discharge and at 6 months follow-up. RESULTS: PVL was none/trace in 10 (33%), mild in 18 (60%) and moderate in 2 (7%) patients and occurred in distinct locations with largest EROAs in the area of the left coronary cusp and its adjacent commissures. Independent predictors for EROA were implantation depth (r coefficient -1.9 mm2 per mm implantation depth, p=0.01), leaflet calcification (6.2 mm2 per calcification grade, p=0.03) and THV size L (7.6 mm2 more than size S or M, p=0.01). At 6 months follow-up, EROA decreased by 29% from 13.7±9.7 mm2 to 9.5±7.9 mm2 (p<0.01). Patients with smaller EROAs were more likely to be in New York Heart Association class 1 than patients with larger EROAs (p<0.01). CONCLUSIONS: PVL occurred predominantly in the region of the left coronary cusp and decreased by 29% during 6 months of follow-up. Our results underscore the importance of adequate patient selection and optimal implantation depth.


Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/diagnóstico , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/diagnóstico , Ecocardiografia Transesofagiana , Feminino , Seguimentos , Humanos , Masculino , Tomografia Computadorizada Multidetectores/métodos , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Estudos Retrospectivos
14.
Interv Cardiol Clin ; 9(4): 433-440, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32921367

RESUMO

Many patients presenting with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (CAD). Following successful primary percutaneous coronary intervention (PCI) of culprit lesion, whether to routinely revascularize nonculprit lesions or treat them medically has been debated. Recently, the large-scale, multinational COMPLETE trial definitively established benefit of routine, staged, angiographically guided nonculprit lesion PCI in reducing hard clinical outcomes, including the composite of death from cardiovascular causes or new myocardial infarction, with no major safety concerns. A strategy of complete revascularization with routine nonculprit lesion PCI in suitable lesions should be standard of care in STEMI with multivessel CAD.


Assuntos
Revascularização Miocárdica/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Ensaios Clínicos como Assunto , Angiografia Coronária , Eletrocardiografia , Humanos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico
15.
J Am Coll Cardiol ; 76(11): 1277-1286, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32912441

RESUMO

BACKGROUND: In the COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial, angiography-guided percutaneous coronary intervention (PCI) of nonculprit lesions with the aim of complete revascularization reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (MI) and multivessel coronary artery disease. OBJECTIVES: The purpose of this study was to determine the effect of nonculprit-lesion stenosis severity measured by quantitative coronary angiography (QCA) on the benefit of complete revascularization. METHODS: Among 4,041 patients randomized in the COMPLETE trial, nonculprit lesion stenosis severity was measured using QCA in the angiographic core laboratory in 3,851 patients with 5,355 nonculprit lesions. In pre-specified analyses, the treatment effect in patients with QCA stenosis ≥60% versus <60% on the first coprimary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischemia-driven revascularization was determined. RESULTS: The first coprimary outcome was reduced with complete revascularization in the 2,479 patients with QCA stenosis ≥60% (2.5%/year vs. 4.2%/year; hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47 to 0.79), but not in the 1,372 patients with QCA stenosis <60% (3.0%/year vs. 2.9%/year; HR: 1.04; 95% CI: 0.72 to 1.50; interaction p = 0.02). The second coprimary outcome was reduced in patients with QCA stenosis ≥60% (2.9%/year vs. 6.9%/year; HR: 0.43; 95% CI: 0.34 to 0.54) to a greater extent than patients with QCA stenosis <60% (3.3%/year vs. 5.2%/year; HR: 0.65; 95% CI: 0.47 to 0.89; interaction p = 0.04). CONCLUSIONS: Among patients with ST-segment elevation MI and multivessel coronary artery disease, complete revascularization reduced major CV outcomes to a greater extent in patients with stenosis severity of ≥60% compared with <60%, as determined by quantitative coronary angiography.


Assuntos
Doença da Artéria Coronariana/cirurgia , Revascularização Miocárdica/tendências , Intervenção Coronária Percutânea/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Índice de Gravidade de Doença , Idoso , Angiografia Coronária/métodos , Angiografia Coronária/tendências , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/métodos , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Resultado do Tratamento
18.
Cardiol Res Pract ; 2020: 9583409, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32377430

RESUMO

INTRODUCTION: The natural course of atrial fibrillation (AF) is not well defined. We aimed to investigate the change in AF burden over time and its associated risk factors among AF patients. METHODS: Fifty-four participants with recently documented paroxysmal or persistent AF were enrolled. Main exclusion criteria were permanent AF or previous catheter ablation for AF. AF burden was calculated as time in AF divided by total recording time using yearly continuous 7-day Holter-ECG recordings. A relative change ≥10% or an absolute change >0.5% in AF burden between two yearly Holter-ECG recordings was considered significant. RESULTS: Mean age was 67 years, 72% were men. The proportion of patients with no recorded AF increased from 53.7% at baseline to 78.6% (p=0.1) after 4 years of follow-up. In 7-day Holter-ECG recordings performed after baseline, 23.7% of participants had a decrease and 23.7% an increase in AF burden. In separate mixed effect models, AF burden over time was associated with prior stroke (ß 42.59, 95% CI (23.40; 61.77); p < 0.0001), BNP (ß 0.05, CI (0.02; 0.09); p=0.005) end-diastolic (ß 0.49, CI (0.23; 0.74); p=0.0003) as well as end-systolic (ß 0.25, CI (0.05; 0.46); p=0.02) left atrial volume, left atrial ejection fraction (ß -0.43, CI (-0.76;-0.10); p=0.01), E-wave (ß 36.67, CI (12.96; 60.38); p=0.003), and deceleration time (ß -0.1, CI (-0.16; -0.05); p=0.002). In a multivariable model, a history of prior stroke (ß 29.87, CI (2.61; 57.13); p=0.03) and BNP levels (ß 0.05, CI (0.01; 0.08); p=0.007) remained significantly associated with AF burden. CONCLUSIONS: Few patients with paroxysmal or persistent AF have AF episodes on yearly 7-day Holter-ECG recordings, and AF progression is rare. AF burden was independently associated with a history of prior stroke and BNP levels.

19.
J Am Heart Assoc ; 9(9): e015334, 2020 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-32316803

RESUMO

Background Previous reports have described a leveling off of mortality from premature coronary artery disease (CAD). In recent years, the prevalence of cardiovascular risk factors has increased in rural communities and young adults. Methods and Results We extracted CAD mortality rates from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database from 1999 to 2017, focusing on mortality from premature CAD (defined as <65 years of age in women) and urban-rural differences. Variations in mortality rates over time, assessed with Joinpoint regression modeling, are expressed as estimated annual percentage change (95% CI) and stratified by urbanization, sex, age, and race. Age-adjusted mortality rates decreased for women and men. Stratification by urbanization revealed that premature CAD mortality is stagnating among women in rural areas. However, this stagnation conceals a statistically significant increase in CAD mortality rates since 2009 in women aged 55 to 64 years (estimated annual percentage change: +1.4%; 95% CI, +0.3% to +2.5%) and since 1999 in women aged 45 to 54 years (estimated annual percentage change: +0.6%; 95% CI, +0.2% to 1.0%). Since 1999, mortality has been stagnating in the youngest group (aged 35-44 years; estimated annual percentage change: +0.2%; 95% CI, -0.4% to +0.8%). Stratification by race indicated an increase in mortality rates among white rural women. Premature CAD mortality remains consistently higher in the rural versus urban United States, regardless of sex, race, and age group. Conclusions Premature CAD mortality rates have declined over time. However, stratification by sex and urbanization reveals disparities that would otherwise remain concealed: CAD mortality rates have increased among women from rural areas since at least 2009.


Assuntos
Doença da Artéria Coronariana/mortalidade , Disparidades nos Níveis de Saúde , Mortalidade Prematura/tendências , Saúde da População Rural/tendências , Saúde da Mulher/tendências , Adulto , Doença da Artéria Coronariana/diagnóstico , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Masculino , Saúde do Homem/tendências , Pessoa de Meia-Idade , Medição de Risco , Fatores Sexuais , Fatores de Tempo , Estados Unidos/epidemiologia
20.
Open Heart ; 7(1): e001204, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32076567

RESUMO

Introduction: Stent underexpansion is a predictor of in-stent-restenosis and stent thrombosis. Semi-compliant balloons (SCBs) are generally used for lesion preparation. It remains unknown whether routine predilatation using non-compliant balloons (NCBs) improves stent expansion in ordinary coronary lesions. Methods: The PREdilatation by high-pressure NC balloon catheter for better vessel preparation and Optimal lesion preparation with non-compliant balloons for the implantation of bioresorbable vascular scaffolds studies randomised patients presenting with stable coronary artery disease or non-ST-elevation myocardial infarction requiring stent implantation to lesion preparation using NCBs versus SCBs. Stent expansion index (SEI-minimal luminal area/mean luminal area on optical coherence tomography) and periprocedural complications were compared. Results: We enrolled 104 patients: 53 patients (54 lesions) vs 51 patients (56 lesions) to the NCB and SCB groups, respectively. Predilatation pressure was higher in the NCB group (24±7 atmospheres (atm) vs 14±3 atm, p<0.0001). Postdilatation using NCBs was performed in 41 (76%) lesions vs 46 (82%) lesions pretreated with NCBs versus SCBs (p=0.57). Similar pressures were used for postdilatation with NCB in both groups (23±8 atm vs 23±9 atm, p=0.65). SEI after stent implantation was 0.88±0.13 in the NCB vs 0.85±0.14 in the SCB group (p=0.18). After postdilatation, SEI increased to 0.94±0.13 in the NCB group vs 0.88±0.13 in the SCB group (p=0.02). No relevant complications occurred. Conclusions: In simple coronary lesions, predilatation/postdilatation with NCBs at high pressures appears to result in better scaffold and stent expansion. Using SCBs only for predilatation might lead to inadequate stent expansion and postdilatation with NCBs might only partially correct this. Predilatation and postdilatation using NCBs at high pressure is safe. Trial registration number: ClinicalTrials.gov no. NCT03518645.


Assuntos
Implantes Absorvíveis , Angioplastia Coronária com Balão/instrumentação , Cateteres Cardíacos , Doença da Artéria Coronariana/terapia , Vasos Coronários/diagnóstico por imagem , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Stents , Tomografia de Coerência Óptica , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico por imagem , Valor Preditivo dos Testes , Pressão , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
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