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Circ Cardiovasc Interv ; 13(9): e009177, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32838554


BACKGROUND: Bleeding and myocardial infarction (MI) after percutaneous coronary intervention are independent risk factors for mortality. This study aimed to investigate the association of all-cause mortality after percutaneous coronary intervention with site-reported bleeding and MI, when considered as individual, repeated, or combined events. METHODS: We used the data from the GLOBAL LEADERS trial (GLOBAL LEADERS: A Clinical Study Comparing Two Forms of Anti-Platelet Therapy After Stent Implantation), an all-comers trial of 15 968 patients undergoing percutaneous coronary intervention. Bleeding was defined as Bleeding Academic Research Consortium (BARC) 2, 3, or 5, whereas MI included periprocedural and spontaneous MIs according to the Third Universal Definition. RESULTS: At 2-year follow-up, 1061 and 498 patients (6.64% and 3.12%) experienced bleeding and MI, respectively. Patients with a bleeding event had a 10.8% mortality (hazard ratio [HR], 5.97 [95% CI, 4.76-7.49]; P<0.001), and the mortality of patients with an MI was 10.4% (HR, 5.06 [95% CI, 3.72-6.90]; P<0.001), whereas the overall mortality was 2.99%. Albeit reduced over time, MI and even minor BARC 2 bleeding significantly influenced mortality beyond 1 year after adverse events (HR of MI, 2.32 [95% CI, 1.18-4.55]; P=0.014, and HR of BARC 2 bleeding, 1.79 [95% CI, 1.02-3.15]; P=0.044). The mortality rates in patients with repetitive bleeding, repetitive MI, and both bleeding and MI were 16.1%, 19.2%, and 19.0%, and their HRs for 2-year mortality were 8.58 (95% CI, 5.63-13.09; P<0.001), 5.57 (95% CI, 2.53-12.25; P<0.001), and 6.60 (95% CI, 3.44-12.65; P<0.001), respectively. De-escalation of antiplatelet therapy at the time of BARC 3 bleeding was associated with a lower subsequent bleeding or MI rate, compared with continuation of antiplatelet therapy (HR, 0.32 [95% CI, 0.11-0.92]; P=0.034). CONCLUSIONS: The fatal impact of bleeding and MI persisted beyond one year. Additional bleeding or MIs resulted in a poorer prognosis. De-escalation of antiplatelet therapy at the time of BARC 3 bleeding could have a major safety merit. These results emphasize the importance of considering the net clinical benefit including ischemic and bleeding events. Registration: URL: Unique identifier: NCT01813435.

Artigo em Inglês | MEDLINE | ID: mdl-32552523


Endovascular Therapeutic hypothermia (ETH) reduces the damage caused by postischemia reperfusion injury syndrome in cardiopulmonary arrest and has already established its role in patients with sudden death; however, its role in ST-segment elevation myocardial infarction (STEMI) remains controversial. The objectives of this study were to investigate the safety, feasibility, and 30-day efficacy of rapid induction of therapeutic hypothermia as adjunctive therapy to percutaneous coronary intervention (PCI) in patients with anterior and inferior STEMIs. This was a prospective, controlled, randomized, two-arm, prospective, interventional study of patients admitted to the emergency department within 6 hours of angina onset, with anterior or inferior STEMI eligible for PCI. Subjects were randomized to the hypothermia group (primary PCI+ETH) or to the control group (primary PCI) at a 4:1 ratio. The ETH was induced by 1 L cold saline (1-4°C) associated with the Proteus™ System, by cooling for at least 18 minutes before coronary reperfusion with a target temperature of 32°C ± 1°C. Maintenance of ETH was conducted for 1-3 hours, and active reheating was done at a rate of 1°C/h for 4 hours. Primary safety outcomes were the feasibility of ETH in the absence of (1) door-to-balloon (DTB) delay; (2) major adverse cardiac events (MACE) within 30 days after randomization. The primary outcomes of effectiveness were infarct size (IS) and left ventricular ejection fraction (LVEF) at 30 days. An as-treated statistical analysis was performed. Fifty patients were included: 35 (70%) randomized to the hypothermia group and 15 (30%) to the control group. The mean age was 58 ± 12 years; 78% were men; and associated diseases were 60% hypertension, 42% diabetes, and 72% dyslipidemia. The compromised myocardial wall was anterior in 38% and inferior in 62%, and the culprit vessels were left anterior descending artery (LAD) (40%), right coronary artery (38%), and left circumflex (18%). All 35 patients who attempted ETH (100%) had successful cooling, with a mean endovascular coronary reperfusion temperature of 33.1°C ± 0.9°C. The mean ischemic time was 375 ± 89.4 minutes in the hypothermia group and 359.5 ± 99.4 minutes in the control group. The mean DTB was 92.1 ± 20.5 minutes in the hypothermia group and 87 ± 24.4 minutes in the control group. The absolute difference of 5.1 minutes was not statistically significant (p = 0.509). The MACE rates were similar between both groups (21.7% vs. 20% respectively, p = 0.237). In the comparison between the hypothermia and control groups, no statistically significant differences were observed at 30 days between mean IS (13.9% ± 8% vs. 13.8% ± 10.8%, respectively, p = 0.801) and mean final LVEF (43.3% ± 11.2% vs. 48.3 ± 10.9%, respectively; p = 0.194). Hypothermia as an adjunctive therapy to primary PCI in STEMI is feasible and can be implemented without delay in coronary reperfusion. Hypothermia was safe regarding the incidence of MACE at 30 days. However, there was a higher incidence of arrhythmia and in-hospital infection in the hypothermia group, with no increase in mortality. Regarding efficacy, there was no difference in IS or LVEF at 30 days that would suggest additional myocardial protection with ETH. NCT02664194.

Catheter Cardiovasc Interv ; 96(5): E516-E526, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32294317


OBJECTIVES: We aimed to investigate the prognostic utility of the anatomical CABG SYNTAX and logistic clinical SYNTAX scores for mortality after percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafts (CABG). BACKGROUND: The anatomical SYNTAX score evaluated the anatomical complexity of coronary artery disease and helped predict the prognosis of patients undergoing PCI. The anatomical CABG SYNTAX score was derived from the anatomical SYNTAX score in patients with prior CABG, whilst the logistic clinical SYNTAX score was developed by incorporating clinical factors into the anatomical SYNTAX score. METHODS: We calculated the anatomical CABG SYNTAX score and logistic clinical SYNTAX score in 205 patients in the GLOBAL LEADERS trial. The predictive abilities of these scores for 2-year all-cause mortality were evaluated. RESULTS: Using the median scores as categorical thresholds between low and high score groups, the logistic clinical SYNTAX score was able to discriminate the risk of 2-year mortality, unlike the anatomical CABG SYNTAX score. The logistic clinical SYNTAX was significantly better at predicting 2-year mortality, compared to the anatomical CABG SYNTAX score, as evidenced by AUC values in receiver-operating characteristic curve analysis (0.806 vs. 0.582, p < .001) and integrated discrimination improvement (0.121, p < .001). CONCLUSIONS: The logistic clinical SYNTAX score was superior to the anatomical CABG SYNTAX score in predicting 2-year mortality.

Catheter Cardiovasc Interv ; 89(3): 429-436, 2017.
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1061861


OBJECTIVES: This study aimed to compare gender-related differences in outcomes of patients undergoing TAVI over a long-term follow-up period.BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been considered the standard therapy for patients with inoperable or high-risk symptomatic aortic stenosis. The influence of gender-related differences in outcomes of patients undergoing TAVI is currently on debate.METHODS: From January 2008 to January 2015, 819 patients (49% men) underwent TAVI and were included in a multicenter Brazilian registry. Patients were followed-up and clinical outcomes were evaluated according to the updated Valve Academic Research Consortium-2 criteria. RESULTS: Mean follow-up was 497 ± 478 days. Compared with women, men had a lower rate of major or life-threatening bleeding (12.0% vs. 20.6%; HR = 0.57 [95CI% 0.40-0.81]; P = 0.001), and major vascular complications (6% vs. 11.7%; HR = 0.50 [95CI% 0.31-0.82]; P = 0.004). At 30 days, all-cause mortality was lower in men than in women (6.5% vs. 11.5%; P = 0.013), however, cumulative all-cause mortality was similar between groups (25.9% vs. 29.7%, men and women, respectively, HR = 0.92 [95CI% 0.71-1.19]; P = 0.52) over the entire follow-up period. By adjusted Cox regression model, renal function, diabetes, peripheral artery disease, and chronic obstructive pulmonary disease (COPD) remained independently predictors of all-cause mortality...

Estenose da Valva Aórtica , Identidade de Gênero , Pacientes
Rev. bras. cardiol. invasiva ; 23(2): 130-133, abr.-jun. 2016. tab, graf
Artigo em Português | LILACS | ID: lil-786996


Introdução: A medida acurada do tamanho do anel valvar aórtico tem importância fundamental para o planejamento do implante percutâneo de prótese valvar aórtica transcateter (TAVI) em pacientes comestenose valvar aórtica grave. Embora haja recomendação de se realizar a medida na sístole, pouco se sabe sobre a importância das diferenças entre as dimensões sistólica e diastólica do anel. Métodos: Pacientes consecutivos referidos para TAVI foram avaliados com tomografia computadorizada para medida do anel valvar na sístole e na diástole. Área, circunferência, diâmetros máximo e mínimo, e seus diâmetros médios derivados foram obtidos em ambas as fases do ciclo cardíaco. Gráficos de Bland Altman foram construídos para se avaliarem as diferenças entre as medidas.Resultados: Foram incluídos na análise 41 pacientes com estenose aórtica grave. As médias da área, circunferência e diâmetros médios foram discretamente maiores na sístole. No entanto, em 35% dos pacientes, as dimensões diastólicas foram maiores. Essas diferenças, embora estatisticamente significantes, foram pequenas (a maior diferença de 0,6 mm no diâmetro médio). Gráficos de Bland Altman revelaram bons níveis de concordância entre as medidas sistólicas e diastólicas em todos os parâmetros avaliados.Conclusões: Observamos pequenas diferenças nas dimensões sistólicas e diastólicas no anel valvar aórtico à tomografia computadorizada, as quais, embora estatisticamente significantes, provavelmente não impactam na seleção da prótese e nem no resultado do procedimento.

Background: Accurate aortic valve annulus sizing has critical importance for the planning of percutaneous transcatheter aortic valve implantation (TAVI) in patients with severe aortic valve stenosis. Although there is a recommendation to perform the measurement during systole, little is known about the importance of the differences between systolic and diastolic dimensions of the annulus. Methods: Consecutive patients referred for TAVI were evaluated with computed tomography for valve annulus sizing during systole and diastole. Area, circumference, minimum and maximum diameters, and their mean derived diameters were obtained in both phases of the cardiac cycle. Bland-Altman plots were constructed to evaluate the differences between the measures. Results: The analysis included 41 patients with severe aortic stenosis. Mean area, circumference, and diameters were slightly greater in systole. However, in 35% of patients, diastolic dimensions were greater.These differences, although statistically significant, were small (the greatest difference of 0.6 mm in mean diameter). Bland-Altman plots showed good agreement between systolic and diastolic measurements on all parameters evaluated Conclusions: Small differences were observed in the systolic and diastolic dimensions of the aortic valve annulus with computed tomography scan, which, although statistically significant, probably do not impact the selection of prosthesis or the procedure outcome.

Humanos , Masculino , Feminino , Idoso de 80 Anos ou mais , Diástole/fisiologia , Sístole/fisiologia , Substituição da Valva Aórtica Transcateter/métodos , Tomografia Computadorizada por Raios X/métodos , Artéria Femoral/cirurgia , Ecocardiografia/métodos , Estenose da Valva Aórtica/terapia , Implantação de Prótese , Análise Estatística
Rev. Soc. Cardiol. Estado de Säo Paulo ; 26(2): 128-133, abr.-jun.2016. tab
Artigo em Português | LILACS | ID: lil-796517


Aproximadamente 30% dos pacientes que se apresentam com quadro de síndrome coronariana aguda têm revascularização prévia do miocárdio. Os eventos coronarianos subsequentes à revascularização do miocárdio podem ocorrer por progressão da doença aterosclerótica no leito coronário nativo, evento relacionado ao stent (reestenose, trombose ou neoaterosclerose) ou evento relacionado à cirurgia de revascularização domiocárdio (degeneração ou oclusão de enxertos cirúrgicos). Esses pacientes que necessitamde um novo procedimento de revascularização têm perfil de alto risco, geralmente associado a doença renal crônica, diabetes mellitus, doença arterial periférica, além deelevada carga aterosclerótica no leito coronariano nativo, degeneração de enxertos de veia safena e reestenose de stents. Este cenário faz com que o segundo procedimento de revascularização tenha maior risco e maior complexidade. Neste artigo discutiremos as características clínicas e as possibilidades terapêuticas de pacientes com SCA e revascularização percutânea ou cirúrgica prévias.

Around 30% of patients who present acute coronary syndrome have undergone previous myocardial revascularization. Coronary events following myocardial revascularization can occur due to progression of atherosclerotic disease in the native coronary bed, an event related to the stent (restenosis, thrombosis or neoatherosclerosis) or to the myocardial revascularization surgery (degeneration or occlusion of surgical grafts). These patients who need a new revascularization procedure have a high-risk profile, generally associated with chronic kidney disease, diabetes mellitus, and peripheral arterial disease, as well as a high atherosclerotic burden in the native coronary bed, degeneration of grafts of the saphenous vein, and restenosis of stents. This scenario confers a higher risk and greater complexity on the second revascularization procedure. In this article, we discuss the clinical characteristics and therapeutic possibilities of patients with ACS and previous percutaneous or surgical revascularization.

Humanos , Intervenção Coronária Percutânea/métodos , Reestenose Coronária/diagnóstico , Reestenose Coronária/terapia , Revascularização Miocárdica/efeitos adversos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Doença Aguda , Angioplastia/métodos , Ventrículos do Coração , Fatores de Risco , Veia Safena , Stents , Trombose/diagnóstico , Trombose/terapia , Vasos Coronários/cirurgia
Rev Assoc Med Bras (1992) ; 62(1): 32-7, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27008490


INTRODUCTION: the EuroSCORE II and STS are the most used scores for surgical risk stratification and indication of transcatheter aortic valve implantation (TAVI). However, its role as a tool for mortality prediction in patients undergoing TAVI is still unclear. OBJECTIVE: to evaluate the performance of the EuroSCORE II and STS as predictors of in-hospital and 30-day mortality in patients undergoing TAVI. METHODS: we included 59 symptomatic patients with severe aortic stenosis that underwent TAVI between 2010 and 2014. The variables were analyzed using Student's t-test and Fisher's exact test and the discriminative power was evaluated using receiver operating characteristic curve (ROC) and area under the curve (AUC) with a 95% confidence interval. RESULTS: mean age was 81±7.3 years, 42.3% men. The mean EuroSCORE II was 7.6±7.3 % and STS was 20.7±10.3%. Transfemoral procedure was performed in 88.13%, transapical in 3.38% and transaortic in 8.47%. In-hospital mortality was 10.1% and 30-day mortality was 13.5%. Patients who died had EuroSCORE II and STS higher than the survivors (33.7±16.7vs. 18.6±7.3% p=0,0001 for STS and 13.9±16.1 vs. 4.8±3.8% p=0.0007 for EuroSCORE II). The STS showed an AUC of 0.81 and the EuroSCORE II of 0.77 and there were no differences in the discrimination ability using ROC curves (p=0.72). CONCLUSION: in this cohort, the STS and EuroSCORE II were predictors of in-hospital and 30-days mortality in patients with severe aortic stenosis undergoing TAVI.

Medição de Risco/métodos , Substituição da Valva Aórtica Transcateter/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Brasil , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Substituição da Valva Aórtica Transcateter/efeitos adversos
Rev. Assoc. Med. Bras. (1992) ; 62(1): 32-37, Jan.-Feb. 2016. tab, graf
Artigo em Inglês | LILACS-Express | LILACS | ID: lil-777440


SUMMARY Introduction: the EuroSCORE II and STS are the most used scores for surgical risk stratification and indication of transcatheter aortic valve implantation (TAVI). However, its role as a tool for mortality prediction in patients undergoing TAVI is still unclear. Objective: to evaluate the performance of the EuroSCORE II and STS as predictors of in-hospital and 30-day mortality in patients undergoing TAVI. Methods: we included 59 symptomatic patients with severe aortic stenosis that underwent TAVI between 2010 and 2014. The variables were analyzed using Student's t-test and Fisher's exact test and the discriminative power was evaluated using receiver operating characteristic curve (ROC) and area under the curve (AUC) with a 95% confidence interval. Results: mean age was 81±7.3 years, 42.3% men. The mean EuroSCORE II was 7.6±7.3 % and STS was 20.7±10.3%. Transfemoral procedure was performed in 88.13%, transapical in 3.38% and transaortic in 8.47%. In-hospital mortality was 10.1% and 30-day mortality was 13.5%. Patients who died had EuroSCORE II and STS higher than the survivors (33.7±16.7vs. 18.6±7.3% p=0,0001 for STS and 13.9±16.1 vs. 4.8±3.8% p=0.0007 for EuroSCORE II). The STS showed an AUC of 0.81 and the EuroSCORE II of 0.77 and there were no differences in the discrimination ability using ROC curves (p=0.72). Conclusion: in this cohort, the STS and EuroSCORE II were predictors of in-hospital and 30-days mortality in patients with severe aortic stenosis undergoing TAVI.

RESUMO Introdução: STS e EuroSCORE II são os escores mais utilizados para a estratificação de risco cirúrgico e indicação do implante de válvula aórtica transcateter (TAVI). Entretanto, seu papel como ferramenta para predição de mortalidade em pacientes submetidos ao TAVI ainda é incerto. Objetivo: avaliar o desempenho do EuroSCORE II e STS como preditores de mortalidade intra-hospitalar em 30 dias em pacientes submetidos ao TAVI. Métodos: 59 pacientes com estenose aórtica importante submetidos ao TAVI entre 2010 e 2014. Variáveis foram analisadas por meio do teste t-Student e teste exato de Fisher, e o poder discriminativo foi avaliado pela curva ROC e área sob a curva, acompanhada de intervalo de confiança de 95%. Resultados: a idade média foi de 81±7,3 anos, 42,3% homens. Média do EuroSCORE II foi de 6,07±7,3%, e do STS, 20,7±10,3%. Procedimento transfemoral foi realizado em 88,13%, transapical, em 3,38% e transaórtico, em 8,47%. A mortalidade intra-hospitalar foi 10,1%, e em 30 dias, 13,5%. Os pacientes que evoluíram para óbito apresentavam STS e EuroSCORE II mais elevados que os sobreviventes (33,7±16,7% vs. 18,6±7,3%; p=0,0001 para STS e 13,9±16,1% vs. 4,8±3,8%; p=0,0007 para EuroSCORE II). O STS apresentou AUC de 0,81, e o EuroSCORE II, 0,77. Não houve diferença na capacidade de discriminação pelas curvas ROC (p=0,72). Conclusão: STS e EuroSCORE II foram preditores de mortalidade intra-hospitalar em 30 dias.

Hypertension ; 67(3): 613-22, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26781284


Whole-vessel remodeling critically determines lumen caliber in vascular (patho)physiology, and it is reportedly redox-dependent. We hypothesized that the cell-surface pool of the endoplasmic reticulum redox chaperone protein disulfide isomerase-A1 (peri/epicellular=pecPDI), which is known to support thrombosis, also regulates disease-associated vascular architecture. In human coronary atheromas, PDI expression inversely correlated with constrictive remodeling and plaque stability. In a rabbit iliac artery overdistension model, there was unusually high PDI upregulation (≈25-fold versus basal, 14 days postinjury), involving both intracellular and pecPDI. PecPDI neutralization with distinct anti-PDI antibodies did not enhance endoplasmic reticulum stress or apoptosis. In vivo pecPDI neutralization with PDI antibody-containing perivascular gel from days 12 to 14 post injury promoted 25% decrease in the maximally dilated arteriographic vascular caliber. There was corresponding whole-vessel circumference loss using optical coherence tomography without change in neointima, which indicates constrictive remodeling. This was accompanied by decreased hydrogen peroxide generation. Constrictive remodeling was corroborated by marked changes in collagen organization, that is, switching from circumferential to radial fiber orientation and to a more rigid fiber type. The cytoskeleton architecture was also disrupted; there was a loss of stress fiber coherent organization and a switch from thin to medium thickness actin fibers, all leading to impaired viscoelastic ductility. Total and PDI-associated expressions of ß1-integrin, and levels of reduced cell-surface ß1-integrin, were diminished after PDI antibody treatment, implicating ß1-integrin as a likely pecPDI target during vessel repair. Indeed, focal adhesion kinase phosphorylation, a downstream ß1-integrin effector, was decreased by PDI antibody. Thus, the upregulated pecPDI pool tunes matrix/cytoskeleton reshaping to counteract inward remodeling in vascular pathophysiology.

Estenose Coronária/genética , Vasos Coronários/patologia , Isomerases de Dissulfetos de Proteínas/genética , RNA/genética , Remodelação Vascular , Animais , Membrana Celular/metabolismo , Células Cultivadas , Estenose Coronária/metabolismo , Estenose Coronária/patologia , Vasos Coronários/metabolismo , Retículo Endoplasmático/metabolismo , Estresse do Retículo Endoplasmático , Humanos , Masculino , Fosforilação , Isomerases de Dissulfetos de Proteínas/biossíntese , Coelhos
In. Kalil Filho, Roberto; Fuster, Valetim; Albuquerque, Cícero Piva de. Medicina cardiovascular reduzindo o impacto das doenças / Cardiovascular medicine reducing the impact of diseases. São Paulo, Atheneu, 2016. p.361-373.
Monografia em Português | LILACS | ID: biblio-971545
In. Kalil Filho, Roberto; Fuster, Valetim; Albuquerque, Cícero Piva de. Medicina cardiovascular reduzindo o impacto das doenças / Cardiovascular medicine reducing the impact of diseases. São Paulo, Atheneu, 2016. p.631-654.
Monografia em Português | LILACS | ID: biblio-971558
Rev. bras. cardiol. invasiva ; 23(4)out.-dez. 2015. tab
Artigo em Português | LILACS | ID: biblio-846599


Introdução:Recentemente, o estudo MOZART demonstrou que a utilização do ultrassom intracoronário (USIC) para guiar a intervenção coronariana percutânea (ICP) diminui o volume de contraste utilizado no procedimento. Avaliamos a incidência de eventos adversos cardiovasculares tardios desses pacientes. Métodos: Pacientes com risco para nefropatia induzida por contraste (NIC) ou para sobrecarga de volume, e com indicação de ICP, foram randomizados para procedimento guiado pela angiografia ou USIC, e acompanhados por um período de 1 ano. Resultados: Incluídos 83 pacientes nos grupos ICP guiado por angiografia (n = 42) ou USIC (n = 41), sendo que 77,1% eram diabéticos e 44,6% tinham clearance de creatinina < 60mL/min/1,73m2. As características clínicas e angiográficas não mostraram diferenças entre os grupos. A maioria tinha lesões tipo B2/C (89,8%) e uma mediana de dois stents foram usados (intervalo interquartil: 1,0­2,0 stents). O tempo de procedimento da ICP guiada por USIC foi 14 minutos maior do que no grupo guiado por angiografia (p = 0,006). No entanto, os grupos não diferiram em relação ao tempo de fluoroscopia ou à média de aquisições de imagem por procedimento. A NIC ocorreu em 19,0% vs. 7,3% (p = 0,26). No período de seguimento de 1 ano, 12% dos pacientes apresentaram algum evento cardiovascular maior, sendo dois óbitos (um para cada grupo), e não houve diferenças entre os grupos. Conclusões: A estratégia de redução de contraste com a ICP guiada pelo ultrassom intravascular, em pacientes com risco para NIC ou sobrecarga de volume, mostrou­se segura a curto e longo prazos.

Background: Recently, the MOZART study demonstrated that using intravascular ultrasound (IVUS) for guiding percutaneous coronary intervention (PCI) reduces the volume of contrast used in the procedure. The authors assessed the incidence of late adverse cardiovascular events in these patients. Methods: Patients at risk for contrast­induced nephropathy (CIN) or volume overload were randomized to angiography­guided versus IVUS­guided PCI, and followed­up for a 1­year period. Results: Eighty­three patients were included in the angiography­guided (n = 42) or IVUS­guided (n = 41) groups, of whom 77.1% were diabetics and 44.6% had creatinine clearance < 60mL/min/1.73m2. Clinical and angiographic characteristics did not differ between the groups. Most had type B2/C lesions (89.8%) and a median of two stents were used (interquartile range: 1.0­2.0 stents). The duration of IVUS­guided PCI was 14minutes longer than the angiography­guided PCI group (p = 0.006). However, the groups did not differ regarding fluoroscopy time or mean image acquisitions per procedure. CIN occurred in 19.0% vs. 7.3% (p = 0.26). During the 1­year follow­up, 12% of patients had a major cardiovascular event, with two deaths (one in each group), and no differences were found between groups. Conclusions: The contrast reduction strategy with IVUS­guided PCI in patients at risk for CIN or volume overload was shown to be safe in the short and long term

Humanos , Masculino , Feminino , Meios de Contraste/administração & dosagem , Intervenção Coronária Percutânea/métodos , Resultado do Tratamento , Ultrassonografia/métodos , Angiografia/métodos , Doenças Cardiovasculares/fisiopatologia , Creatinina , Diagnóstico por Imagem/métodos , Estudos Prospectivos , Análise Estatística , Stents
Rev. bras. cardiol. invasiva ; 23(4): f:279-l:281, out.-dez. 2015. ilus
Artigo em Português | LILACS | ID: biblio-846619


A dissecção coronária espontânea é uma entidade rara e, por conseguinte, de etiologia, fisiopatologia e tratamento ainda não estabelecidos. Acomete, em geral, mulheres jovens, sem os clássicos fatores de risco cardiovascular, comumente ao longo do ciclo gravídico-puerperal. Vários fatores influenciam na estratégia de tratamento, como quadro clínico, status hemodinâmico, topografia da dissecção, número de artérias afetadas e fluxo coronário distal. Como no caso relatado, em pacientes estáveis, com dissecções bem delimitadas e, sobremodo, quando o fluxo coronário é reestabelecido, pode-se optar por uma abordagem conservadora, em razão da alta incidência de resolução espontânea e da baixa incidência de eventos adversos a longo prazo

Spontaneous coronary dissection is a rare entity and, therefore, its etiology, pathophysiology, and treatment are not yet established. It affects mainly young women without the classic cardiovascular risk factors, commonly during the pregnancy-childbirth cycle. Several factors influence the treatment strategy, such as clinical presentation, hemodynamic status, topography, number of affected arteries, and distal coronary flow. As in the reported case, in stable patients with well-defined dissections and mainly when the coronary flow has been re-established, one can choose a conservative approach, due to the high incidence of spontaneous resolution and low incidence of long-term adverse events

Humanos , Feminino , Pessoa de Meia-Idade , Doença das Coronárias/terapia , Dissecação/métodos , Terapêutica , Angiografia/métodos , Diagnóstico Clínico/diagnóstico , Vasos Coronários/cirurgia , Prognóstico
Arq Bras Cardiol ; 105(2 Suppl 1): 1-105, 2015 Aug.
Artigo em Português | MEDLINE | ID: mdl-26375058
Rev. bras. cardiol. invasiva ; 23(1): 38-41, abr.-jun.2015. tab, graf
Artigo em Português | LILACS | ID: lil-782173


A aterectomia rotacional com incorporação de novas estratégias ablativas tem sido proposta para o preparo de lesões extremamente calcificadas. Entretanto, pouco se conhece a respeito da adoçãodessas novas estratégias na prática contemporânea e sobre a evolução tardia dos pacientes submetidos aesse tratamento. Objetivamos avaliar os aspectos técnicos da aterectomia e a evolução tardia dos pacientesquanto à ocorrência de eventos cardiovasculares adversos maiores (ECAM). Métodos: Estudo retrospectivo e unicêntrico, incluindo todos os pacientes submetidos à aterectomiarotacional como parte do tratamento de lesões coronárias com calcificação extrema ou falha de dilataçãoem procedimento prévio, no período de julho de 2012 a novembro de 2014. Foram definidos como ECAM: óbito, infarto agudo do miocárdio com onda Q ou nova revascularização do vaso-alvo.Resultados: Foram submetidos à aterectomia 29 pacientes com idade média de 69,5 ± 7,6 anos. A médiada relação oliva/vaso foi de 0,54 ± 0,07; a velocidade de rotação inicial adotada foi de 161.000 ± 13.928 e a taxa de utilização de cutting balloon pós-aterectomia foi de 45,1%. Sucesso angiográfico foi obtido em todos os procedimentos. Na evolução tardia, a mediana de tempo de seguimento foi de 13,2 meses (intervalo interquartil: 4,0 a 17,4 meses). Foram registrados um óbito por causa não cardíaca e duas novas revascularizações do vaso-alvo. A média do tempo de sobrevivência livre de ECAM foi de 29,7 ± 2,1 meses.Conclusões: A aterectomia rotacional contemporânea incorporou estratégias menos agressivas de ablação,com elevada taxa de sucesso imediato e baixa ocorrência de ECAM na evolução tardia...

Rotational atherectomy with new ablative strategies have been proposed for the treatment of extremely calcified lesions prior to stent implantation. Nevertheless, few data are available about the adoption of these new strategies in contemporary practice and about late outcomes of patients undergoing this therapy. Methods: From July 2012 to November 2014, a retrospective single center registry was conducted, including all patients undergoing rotational atherectomy as part of the treatment of coronary arteries with heavy calcification or previous failed dilation. We evaluated technical aspects of atherectomy and late outcomes of patients for the occurrence of major adverse cardiovascular events (MACE), defined as death, Q-wave myocardial infarction or repeat target vessel revascularization.Results: Twenty-nine patients with a mean age of 69.5 ± 7.6 years, underwent atherectomy. The averageburr-to-artery ratio was 0.54 ± 0.07, the initial rotational speed was 161.000 ± 13.928 and the rate of cuttingballoon utilization after atherectomy was 45.1%. Angiographic success was achieved in all procedures. The median follow-up time was 13.2 months (IQ: 4.0-17.4) and there were three events: 1 death of non cardiac cause and 2 new target vessel revascularizations. The mean MACE-free survival time was 29.7 ± 2.1 months. Conclusions: Contemporary rotational atherectomy incorporates less aggressive strategies of ablation with high rates of acute success and low occurrence of major adverse cardiovascular events during late follow-up...

Humanos , Masculino , Feminino , Idoso , Aterectomia Coronária/métodos , Tratamento Farmacológico , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Intervenção Coronária Percutânea/métodos , Angioplastia com Balão/métodos , Aspirina/administração & dosagem , Calcificação Vascular/terapia , Heparina/administração & dosagem , Estudos Retrospectivos , Fatores de Risco
Rev. bras. cardiol. invasiva ; 23(1): 58-60, abr.-jun.2015. tab
Artigo em Português | LILACS | ID: lil-782177


O objetivo deste estudo foi avaliar o grau de acurácia, precisão, correlação e concordância entre as medidas realizadas por um software de angiografia coronária quantitativa (QCA) online de calibração automática. Métodos: Estudo piloto que analisou imagens angiográficas de dez pacientes com um software de QCA online nas calibrações automáticas Auto ISO (calibração automática do isocentro) e Auto TOD (Table-to Object Distance). Foi realizada a medida do calibre do cateter pelos dois métodos, e o diâmetro de referência foi computado. Essas medidas foram comparadas com a medida do diâmetro do cateter quanto à acurácia, precisão e concordância. Resultados: O diâmetro médio real dos cateteres era de 1,75 ± 0,32 mm (variando entre 1,33 e 2,67 mm). A aferição dos cateteres pela QCA TOD e pela QCA ISO resultou em diâmetros médios de 1,78 ± 0,37 mm e 1,88 ± 0,38 mm, respectivamente. A acurácia/precisão da QCA TOD e da QCA ISO foi 0,03 m/0,21 mm e 0,12 mm/0,20 mm, respectivamente. As medidas da QCA TOD e da QCA ISO estiveram entre os limites de concordância em 96,3 e 94,7% dos casos, respectivamente. As medidas da QCA TOD e da QCA ISO correlacionaram-se significativamente (rs = 0,93; p < 0,01). No entanto, apesar da pequena diferença entre os métodos (0,10 ± 0,10 mm), as medidas da QCA ISO foram estatisticamente maiores que aquelas obtidas com a QCA TOD (p < 0,01). Conclusões: A QCA online com calibração automática apresentou boa acurácia, precisão e correlação,podendo representar uma ferramenta promissora no laboratório de hemodinâmica...

The objective of this study was to evaluate the degree of accuracy, precision, correlation, andagreement between the measurements performed by online Quantitative Coronary Angiography (QCA)software with automatic calibration.Methods: Pilot study that analyzed angiographic images of ten patients through online QCA softwareusing Auto ISO (automatic calibration isocenter) and Auto TOD (Table-to-Object Distance) automatic calibration. Catheter size was measured by both methods and the reference diameter was computed. These measurements were compared with the measurement of catheter diameter regarding accuracy, precision,and agreement. Results: The actual average of the catheter diameter was 1.75 ± 0.32 mm (range 1.33 to 2.67 mm). The measurement of catheters by TOD QCA and ISO QCA resulted in mean diameters of 1.78 ± 0.37 mm and 1.88± 0.38 mm, respectively. The accuracy/precision of the TOD QCA and the ISO QCA was 0.03 mm/0.21 mmand 0.12 mm/0.20 mm, respectively. The TOD QCA and ISO QCA measures were among the limits ofagreement in 96.3 and 94.7% of cases, respectively, and were significantly correlated (rs = 0.93, p < 0.01). However, despite the small difference between the methods (0.10 ± 0.10 mm), the ISO QCA measures were significantly higher than those obtained by the TOD QCA (p < 0.01). Conclusions: Online QCA with automatic calibration has good accuracy, precision, and correlation, which may represent a promising tool in the catheterization laboratory...

Humanos , Masculino , Feminino , Angiografia Coronária/métodos , Precisão da Medição Dimensional , Doença das Coronárias/diagnóstico , Doença das Coronárias/terapia , Cateteres , Projetos Piloto , Análise Estatística , Stents
Arq. bras. cardiol ; 103(5): 410-417, 11/2014. tab, graf
Artigo em Inglês | LILACS-Express | LILACS | ID: lil-730366


Background: The hemodynamic effects of noninvasive ventilation with positive pressure in patients with pulmonary hypertension without left ventricular dysfunction are not clearly established. Objectives: Analyze the impact of increasing airway pressure with continuous positive airway pressure on hemodynamic parameters and, in particular, on cardiac output in patients with variable degrees of pulmonary hypertension. Methods: The study included 38 patients with pulmonary hypertension caused by mitral stenosis without left ventricular dysfunction or other significant valvulopathy. The hemodynamic state of these patients was analyzed in three conditions: baseline, after continuous positive pressure of 7 cmH2O and, finally, after pressure of 14 cmH2O. Results: The population was composed of predominantly young and female individuals with significant elevation in pulmonary arterial pressure (mean systolic pressure of 57 mmHg). Of all variables analyzed, only the right atrial pressure changed across the analyzed moments (from the baseline condition to the pressure of 14 cmH2O there was a change from 8 ± 4 mmHg to 11 ± 3 mmHg, respectively, p = 0.031). Even though there was no variation in mean cardiac output, increased values in pulmonary artery pressure were associated with increased cardiac output. There was no harmful effect or other clinical instability associated with use application of airway pressure. Conclusion: In patients with venocapillary pulmonary hypertension without left ventricular dysfunction, cardiac output response was directly associated with the degree of pulmonary hypertension. The application of noninvasive ventilation did not cause complications directly related to the ventilation systems. .

Fundamento: Os efeitos hemodinâmicos da ventilação não invasiva com pressão positiva em pacientes com hipertensão pulmonar sem disfunção ventricular esquerda não estão bem estabelecidos. Objetivos: Analisar o impacto da pressurização aérea crescente através da pressão positiva contínua das vias aéreas nos parâmetros hemodinâmicos e, principalmente, no débito cardíaco de pacientes com graus variáveis de hipertensão pulmonar. Métodos: Foram incluídos 38 pacientes com hipertensão pulmonar causada por estenose mitral sem disfunção ventricular esquerda ou outra valvopatia significativa. O estado hemodinâmico deses pacientes foi estudado em três condições: basal, após uso de pressão positiva contínua de 7 cmH2O e , finalmente, após pressão de 14 cmH2O. Resultados: A população foi composta por indivíduos predominantemente jovens, do sexo feminino e com elevação significativa da pressão arterial pulmonar (pressão sistólica média de 57 mmHg). De todas as variáveis analisadas, apenas a pressão de átrio direito apresentou variação ao longo dos momentos estudados (da condição basal para a de pressão de 14 cmH2O houve aumento de 8 ± 4 mmHg para 11 ± 3 mmHg, respectivamente, p = 0,031). Apesar de não ter havido variação do valor médio do débito cardíaco, valores mais elevados de pressões na artéria pulmonar estiveram associados ao aumento do débito cardíaco. Não houve efeito deletério ou qualquer instabilidade clínica associada ao uso da pressurização das vias aéreas. Conclusão: Em pacientes com hipertensão venocapilar pulmonar sem disfunção ventricular esquerda, a resposta ...