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5.
Int J Cardiol ; 267: 13-15, 2018 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-29861104

RESUMO

BACKGROUND: The National Cardiovascular Data Registry (NCDR®) Database is commonly used for quality-improvement initiatives in North America, but little is known about the application of this tool in other regions of the world. METHODS: All consecutive patients admitted due to myocardial infarction (MI) and/or undergoing percutaneous coronary intervention (PCI) from January 2012 until December 2015 in a Brazilian private cardiovascular hospital were included respectively in ACTION REGISTRY®-GWTG™ and CathPCI Registry®. Meetings including all hospital staff were performed quarterly to discuss every NCDR® report. Quality improvement initiatives were developed based on the reports which were also used for evaluation of changes after the interventions. The following indicators were considered a priority 1) Door-to-ECG and door-to-balloon (D2B) times; 2) PCI appropriateness; 3) length of stay; 4) delivery of guideline-based medication. Changes in the quality of care with respect to the over time were assessed using linear and logistic regression for continuous and binary outcomes, respectively. RESULTS: A total of 1.382 patients were included in the ACTION REGISTRY®-GWTG™ and 3.179 patients in the CathPCI Registry®. In the ACTION registry, the overall AMI performance composite of quality indicators improved along the 4 years from 95.0% to 99.6% (p for trend <0.001). The percentage of appropriate/uncertain PCI in acute and elective scenario increased along the years from 91.1% and 70.9% to 96.6% and 84.7%, respectively (p for trend <0.001). CONCLUSION: The present novel experience using the NCDR® registries as benchmarks to guide quality-improvement programs in an international site was associated with improvement in quality indicators.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Infarto do Miocárdio , Intervenção Coronária Percutânea , Melhoria de Qualidade/organização & administração , Indicadores de Qualidade em Assistência à Saúde/normas , Idoso , Brasil/epidemiologia , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Medição de Risco , Fatores de Risco , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos
6.
J Am Coll Cardiol ; 71(12): 1297-1308, 2018 03 27.
Artigo em Inglês | MEDLINE | ID: mdl-29566812

RESUMO

BACKGROUND: Few data exist on patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Also, very scarce data exist on the usefulness of dobutamine stress echocardiography (DSE) before TAVR in these patients. OBJECTIVES: The authors sought to evaluate clinical outcomes and changes in left ventricular ejection fraction (LVEF) following TAVR in patients with classical LFLG-AS. METHODS: This multicenter registry included 287 patients with LFLG-AS undergoing TAVR. DSE was performed before TAVR in 234 patients and the presence of contractile reserve was defined as an increase of ≥20% in stroke volume. Transthoracic echocardiography was repeated at hospital discharge and at 1-year follow-up. Clinical follow-up was obtained at 1 and 12 months, and yearly thereafter. RESULTS: The median Society of Thoracic Surgeons score of the study population was 7.7% (interquartile range 5.3% to 12.0%), and the mean LVEF and transvalvular gradient were 30.1 ± 9.7% and 25.4 ± 6.6 mm Hg, respectively. The presence of contractile reserve was observed in 45% of patients at DSE. Mortality rates were 3.8%, 20.1%, and 32.3% at 30 days, 1 year, and 2 years, respectively. On multivariable analysis, chronic obstructive pulmonary disease (p = 0.022) and lower hemoglobin values (p < 0.001) were associated with all-cause mortality. Lower hemoglobin values (p = 0.004) and moderate-to-severe aortic regurgitation post-TAVR (p = 0.018) were predictors of the composite of mortality and rehospitalization due to heart failure. LVEF increased by 8.3% (95% confidence interval: 6% to 11%) at 1-year follow-up, and the lack of prior coronary artery bypass graft (p = 0.004), a lower LVEF at baseline (p < 0.001), and a lower stroke volume index at baseline (p = 0.019) were associated with greater increase in LVEF. The absence of contractile reserve at baseline DSE was not associated with any negative effect on clinical outcomes or LVEF changes at follow-up. CONCLUSIONS: TAVR was associated with good periprocedural outcomes in patients with LFLG-AS. However, approximately one-third of LFLG-AS TAVR recipients died at 2-year follow-up, with pulmonary disease, anemia, and residual paravalvular leaks associated with poorer outcomes. LVEF improved following TAVR, but DSE failed to predict clinical outcomes or LVEF changes over time. (Multicenter Prospective Study of Low-Flow Low-Gradient Aortic Stenosis [TOPAS Study]; NCT01835028).


Assuntos
Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Velocidade do Fluxo Sanguíneo/fisiologia , Sistema de Registros , Volume Sistólico/fisiologia , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos
8.
JACC Cardiovasc Imaging ; 9(10): 1145-1158, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27372022

RESUMO

OBJECTIVES: This study sought to evaluate transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) aortic stenosis (AS), with a particular emphasis on TAVR-directed bicuspid aortic valve imaging (BAVi) of morphological classification. BACKGROUND: TAVR has been used to treat BAV-AS but with heterogeneous outcomes and uncertainty regarding the relevance of morphology. METHODS: In 14 centers in the United States, Canada, Europe, and Asia, 130 BAV-AS patients underwent TAVR. Baseline cardiac computed tomography (CT) was analyzed by a dedicated Corelab. Outcomes were assessed in line with Valve Academic Research Consortium criteria. RESULTS: Bicommissural BAV (vs. tricommissural) accounted for 68.9% of those treated in North America, 88.9% in Europe, and 95.5% in Asia (p = 0.003). For bicommissural bicuspids, non-raphe type (vs. raphe type) BAV accounted for 11.9% of those treated in North America, 9.4% in Europe, and 61.9% in Asia (p < 0.001). Overall rates of 30-day mortality (3.8%) and cerebrovascular events (3.2%) were favorable and similar among anatomical subsets. The rate of new permanent pacemaker insertion was high (26.2%) and similar between balloon-expandable (BE) and self-expanding (SE) designs (BE: 25.5% vs. SE: 26.9%; p = 0.83); there was a trend to greater permanent pacemaker insertion in BE TAVR in the presence of coronary cusp fusion BAV morphology. Paravalvular aortic regurgitation (PAR) ≥ moderate was 18.1% overall but lower at 11.5% in those with pre-procedural CT. In the absence of pre-procedural CT, there was an excess of PAR in BE TAVR that was not the case in those with a pre-procedural CT; SE TAVR required more post-dilation. Predictors of PAR included intercommissural distance for bicommissural bicuspids (odd ratio [OR]: 1.37; 95% confidence interval [CI]: 1.02 to 1.84; p = 0.036) and lack of a baseline CT for annular measurement (OR: 3.03; 95% CI: 1.20 to 7.69; p = 0.018). CONCLUSIONS: In this multicenter study, TAVR achieved favorable outcomes in patients with pre-procedural CT, with the exception of high permanent pacemaker rates for all devices and shapes.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/anormalidades , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/cirurgia , Tomografia Computadorizada Multidetectores , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/classificação , Estenose da Valva Aórtica/fisiopatologia , Ásia , Canadá , Europa (Continente) , Feminino , Doenças das Valvas Cardíacas/classificação , Doenças das Valvas Cardíacas/fisiopatologia , Humanos , Masculino , Valor Preditivo dos Testes , Resultado do Tratamento , Estados Unidos
9.
Am J Cardiol ; 118(6): 785-789, 2016 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-27453512

RESUMO

The experience with the transradial approach in percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) in the United States is limited. We looked at the safety and feasibility of a home-made sheathless transradial technique (STT) with regular 8Fr catheters in CTO PCI. In March 2013, we developed an 8Fr STT for CTO PCI. We compared 119 patients who had the STT versus 122 treated with a standard transradial or transfemoral approach. The primary outcomes of interest were major vascular or bleeding site access complications. In a subgroup of patients with bilateral transradial approach, we assessed and compared radial patency 3 to 6 months after the procedure. Technical success rate of the CTO PCI was 93% in both groups. There were no major vascular or bleeding complications in the STT group. Radial hematomas were frequent but grade III occurred in 4 patients (3%) treated with the STT, not different to the incidence in the other group. The STT did not result in any increase in procedure time, contrast use, or radiation dose. Radial Doppler follow-up in 28 patients revealed 2 occlusions (7.1%) on the 8Fr shealthless side and one on the 6Fr side. In conclusion, our STT with regular 8Fr guides for CTO PCI is feasible, safe, and associated with low complication rate. We show that the hybrid CTO PCI nowadays can be performed through transradial access in the majority, with limited use of transfemoral approach.


Assuntos
Oclusão Coronária/cirurgia , Intervenção Coronária Percutânea/instrumentação , Complicações Pós-Operatórias/epidemiologia , Artéria Radial/lesões , Sistema de Registros , Idoso , Doença Crônica , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/diagnóstico por imagem , Artéria Radial/diagnóstico por imagem , Resultado do Tratamento , Ultrassonografia Doppler
10.
Arq Bras Cardiol ; 106(3): 236-46, 2016 Mar.
Artigo em Inglês, Português | MEDLINE | ID: mdl-27027367

RESUMO

Dual antiplatelet therapy is a well-established treatment in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), with class I of recommendation (level of evidence A) in current national and international guidelines. Nonetheless, these guidelines are not precise or consensual regarding the best time to start the second antiplatelet agent. The evidences are conflicting, and after more than a decade using clopidogrel in this scenario, benefits from the routine pretreatment, i.e. without knowing the coronary anatomy, with dual antiplatelet therapy remain uncertain. The recommendation for the upfront treatment with clopidogrel in NSTE-ACS is based on the reduction of non-fatal events in studies that used the conservative strategy with eventual invasive stratification, after many days of the acute event. This approach is different from the current management of these patients, considering the established benefits from the early invasive strategy, especially in moderate to high-risk patients. The only randomized study to date that specifically tested the pretreatment in NSTE-ACS in the context of early invasive strategy, used prasugrel, and it did not show any benefit in reducing ischemic events with pretreatment. On the contrary, its administration increased the risk of bleeding events. This study has brought the pretreatment again into discussion, and led to changes in recent guidelines of the American and European cardiology societies. In this paper, the authors review the main evidence of the pretreatment with dual antiplatelet therapy in NSTE-ACS.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Pré-Medicação/métodos , Ensaios Clínicos como Assunto , Clopidogrel , Humanos , Metanálise como Assunto , Guias de Prática Clínica como Assunto , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Fatores de Tempo
11.
Arq. bras. cardiol ; 106(3): 236-246, Mar. 2016. tab, graf
Artigo em Inglês | LILACS | ID: lil-777103

RESUMO

Abstract Dual antiplatelet therapy is a well-established treatment in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), with class I of recommendation (level of evidence A) in current national and international guidelines. Nonetheless, these guidelines are not precise or consensual regarding the best time to start the second antiplatelet agent. The evidences are conflicting, and after more than a decade using clopidogrel in this scenario, benefits from the routine pretreatment, i.e. without knowing the coronary anatomy, with dual antiplatelet therapy remain uncertain. The recommendation for the upfront treatment with clopidogrel in NSTE-ACS is based on the reduction of non-fatal events in studies that used the conservative strategy with eventual invasive stratification, after many days of the acute event. This approach is different from the current management of these patients, considering the established benefits from the early invasive strategy, especially in moderate to high-risk patients. The only randomized study to date that specifically tested the pretreatment in NSTE-ACS in the context of early invasive strategy, used prasugrel, and it did not show any benefit in reducing ischemic events with pretreatment. On the contrary, its administration increased the risk of bleeding events. This study has brought the pretreatment again into discussion, and led to changes in recent guidelines of the American and European cardiology societies. In this paper, the authors review the main evidence of the pretreatment with dual antiplatelet therapy in NSTE-ACS.


Resumo A indicação de dupla terapia antiplaquetária para o tratamento da síndrome coronariana aguda sem elevação do ST está bem estabelecida e é recomendação classe I (Nível de Evidência A) nas atuais diretrizes nacionais e internacionais. No entanto, essas mesmas diretrizes não são muito claras e consensuais quanto ao melhor momento para utilização do segundo antiplaquetário. As evidências sobre este tema são conflitantes e, após mais de uma década do uso do clopidogrel neste cenário, ainda há discussão se o pré-tratamento com dupla terapia antiplaquetária teria benefício de maneira rotineira, ou seja, quando aplicada sem conhecer a anatomia coronária. A recomendação de tratamentoupfront com clopidogrel na síndrome coronariana aguda sem elevação do ST se baseia em redução de eventos não fatais identificados em estudos que utilizavam estratégia conservadora, com eventual estratificação invasiva tardia, vários dias após o evento agudo. Essa abordagem é bastante diferente da que é feita atualmente, tendo em vista os benefícios já demonstrados da estratégia invasiva precoce nos pacientes de risco intermediário/alto. O único ensaio clínico randomizado que testou a hipótese do pré-tratamento na síndrome coronariana aguda sem elevação do ST sob a atual estratégia invasiva precoce utilizou o antiplaquetário prasugrel e mostrou que não houve benefício em redução de eventos isquêmicos, tendo, por outro lado, aumentado o risco de eventos hemorrágicos. Este estudo trouxe novamente o pré-tratamento à discussão e modificou recomendações nas atuais diretrizes das sociedades americana e europeia de cardiologia. Neste artigo, os autores apresentam uma revisão sobre as principais evidências do pré-tratamento com dupla terapia antiplaquetária na síndrome coronariana aguda sem elevação do ST.


Assuntos
Humanos , Síndrome Coronariana Aguda/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Pré-Medicação/métodos , Ensaios Clínicos como Assunto , Metanálise como Assunto , Guias de Prática Clínica como Assunto , Fatores de Tempo , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico
12.
Heart ; 101(17): 1395-405, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26060121

RESUMO

OBJECTIVES: Mitral regurgitation (MR) is a common entity in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but its influence on outcomes remains controversial. The purpose of this meta-analysis was to assess the clinical impact of and changes in significant (moderate-severe) MR in patients undergoing TAVR, overall and according to valve design (self-expandable (SEV) vs balloon-expandable (BEV)). METHODS: All national registries and randomised trials were pooled using meta-analytical guidelines to establish the impact of moderate-severe MR on mortality after TAVR. Studies reporting changes in MR after TAVR on an individual level were electronically searched and used for the analysis. RESULTS: Eight studies including 8015 patients (SEV: 3474 patients; BEV: 4492 patients) were included in the analysis. The overall 30-day and 1-year mortality was increased in patients with significant MR (OR 1.49, 95% CI 1.16 to 1.92; HR 1.32, 95% CI 1.12 to 1.55, respectively), but a significant heterogeneity across studies was observed (p<0.05). The impact of MR on mortality was not different between SEV and BEV in meta-regression analysis for 30-day (p=0.360) and 1-year (p=0.388) mortality. Changes in MR over time were evaluated in nine studies including 1278 patients. Moderate-severe MR (SEV: 326 patients; BEV: 192 patients) improved in 50.5% of the patients at a median follow-up of 180 (30-360) days after TAVR, and the degree of improvement was greater in patients who had received a BEV (66.7% vs 40.8% in the SEV group, p=0.001). CONCLUSIONS: Concomitant moderate-severe MR was associated with increased early and late mortality following TAVR. A significant improvement in MR severity was detected in half of the patients following TAVR, and the degree of improvement was greater in those patients who had received a BEV.


Assuntos
Estenose da Valva Aórtica/terapia , Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/complicações , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/fisiopatologia , Razão de Chances , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
13.
Circulation ; 131(18): 1566-74, 2015 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-25753535

RESUMO

BACKGROUND: We aimed to determine the incidence, predictors, clinical characteristics, management, and outcomes of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: This multicenter registry included 53 patients (mean age, 79±8 years; men, 57%) who suffered IE after TAVI of 7944 patients after a mean follow-up of 1.1±1.2 years (incidence, 0.67%, 0.50% within the first year after TAVI). Mean time from TAVI was 6 months (interquartile range, 1-14 months). Orotracheal intubation (hazard ratio, 3.87; 95% confidence interval, 1.55-9.64; P=0.004) and the self-expandable CoreValve system (hazard ratio, 3.12; 95% confidence interval, 1.37-7.14; P=0.007) were associated with IE (multivariate analysis including 3067 patients with individual data). The most frequent causal microorganisms were coagulase-negative staphylococci (24%), followed by Staphylococcus aureus (21%) and enterococci (21%). Vegetations were present in 77% of patients (transcatheter valve leaflets, 39%; stent frame, 17%; mitral valve, 21%). At least 1 complication of IE occurred in 87% of patients (heart failure in 68%). However, only 11% of patients underwent valve intervention (valve explantation and valve-in-valve procedure in 4 and 2 patients, respectively). The mortality rate in hospital was 47.2% and increased to 66% at the 1-year follow-up. IE complications such as heart failure (P=0.037) and septic shock (P=0.002) were associated with increased in-hospital mortality. CONCLUSIONS: The incidence of IE at 1 year after TAVI was 0.50%, and the risk increased with the use of orotracheal intubation and a self-expandable valve system. Staphylococci and enterococci were the most common agents. Although most patients presented at least 1 complication of IE, valve intervention was performed in a minority of patients, and nearly half of the patients died during the hospitalization period.


Assuntos
Endocardite Bacteriana/etiologia , Próteses Valvulares Cardíacas/efeitos adversos , Complicações Pós-Operatórias/etiologia , Infecções Relacionadas à Prótese/etiologia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/cirurgia , Endocardite Bacteriana/mortalidade , Endocardite Bacteriana/cirurgia , Enterococcus , Contaminação de Equipamentos , Feminino , Infecções por Bactérias Gram-Positivas/etiologia , Infecções por Bactérias Gram-Positivas/cirurgia , Insuficiência Cardíaca/etiologia , Mortalidade Hospitalar , Humanos , Incidência , Intubação Intratraqueal/efeitos adversos , Estimativa de Kaplan-Meier , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Modelos de Riscos Proporcionais , Infecções Relacionadas à Prótese/mortalidade , Infecções Relacionadas à Prótese/cirurgia , Sistema de Registros , Estudos Retrospectivos , Risco , Infecções Estafilocócicas/etiologia , Infecções Estafilocócicas/cirurgia , Resultado do Tratamento
14.
Interv Cardiol Clin ; 4(1): 67-82, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28582123

RESUMO

Paravalvular regurgitation (PVR) is a frequent complication of transcatheter aortic valve replacement that has been shown to be associated with increased mortality. The objective of this article was to review the most up-to-date information about the impact and management of PVR. A multimodality, multiparametric, integrative approach including angiography, Doppler echocardiography, and/or cardiac MR is essential to accurately assess the severity of PVR and the underlying etiology. Corrective procedures such as balloon postdilation, valve-in-valve, or leak closure may be considered, depending on the severity, location, and etiology of PVR.

15.
Am J Cardiol ; 114(11): 1729-34, 2014 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-25439451

RESUMO

No data exist on the impact of vascular complications related to the secondary access site in transcatheter aortic valve implantation (TAVI). The objectives of this nonrandomized study were to determine the rate of vascular complications related to the secondary access site in TAVI procedures and to evaluate the clinical impact of using the radial versus femoral approach as a secondary access in such procedures. A total of 462 consecutive patients (mean age 79 ± 9 years, 50% men) who underwent TAVI were included. The femoral approach (FA) was used as the secondary access (for the insertion of a 5F pigtail catheter) in 335 patients and the radial approach (RA) in 127 patients. Thirty-day events were prospectively collected. There were no baseline differences between groups, except for a higher prevalence of women and peripheral disease in the FA group (p <0.05 for both). A total of 74 vascular access site complications occurred in 70 patients (15%), and 23% of them (29% in the FA group) were related to the secondary access. The use of FA as secondary access was associated with a higher rate of vascular complications (5.0% vs 0% in the RA group, p = 0.005, adjusted p = 0.014). All major vascular complications related to the secondary access occurred in the FA group (3% vs 0% in the RA group, p = 0.040, adjusted p = 0.049), and this translated into a higher rate of major and/or life-threatening bleeding events related to the secondary access in the FA group (3% vs 0% in the RA group, p = 0.040, adjusted p = 0.049). In conclusion, about 1/4 of vascular access site complications in TAVI are related to the secondary access. The use of the RA as a secondary access was associated with a major reduction in vascular complications. These results highlight the impact of secondary access vascular complications in TAVI procedures and support the use of the RA as the preferred secondary access.


Assuntos
Estenose da Valva Aórtica/cirurgia , Artéria Femoral , Complicações Pós-Operatórias , Artéria Radial , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Estudos Retrospectivos
16.
Am J Cardiol ; 114(9): 1354-60, 2014 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-25242364

RESUMO

New techniques involving dissection of the subintimal space and re-entry into the true lumen increase success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, their long-term safety and efficacy were unknown. This study included a series of consecutive patients who underwent CTO PCI. All patients who did not present events were contacted 12 to 18 months after their PCI. The combined incidence of cardiac death, myocardial infarction, ischemia-driven target-vessel revascularization (TVR), or reocclusion was assessed as our primary outcome. From January 2010 to January 2013, of 212 CTOs treated in our CTO program, 192 (91%) were successfully opened (in 179 patients). Follow-up data were available for 187 CTOs (97.4%), with 82 (44%) that were opened with dissection re-entry and 105 (56%) with conventional wire escalation techniques. At a median follow-up of 398 days, the primary outcome occurred in 18 of 179 CTOs treated (10.7%), driven by TVR. No patient died from cardiac causes. Eleven CTOs (15.2%) treated with dissection re-entry versus 7 CTOs (7.3%) treated with wire escalation presented with the primary outcome (p = 0.17). With multivariate adjustment, dissection re-entry techniques had no significant impact on outcomes. However, treatment of an in-stent occlusion was independently associated with TVR (hazards ratio >6.0, p <0.001). In conclusion, dissection re-entry techniques have minimal impact on long-term outcomes after CTO PCI, which are favorable in most patients. However, treatment of an in-stent occlusion and use of sirolimus-eluting stent were predictors of subsequent adverse outcomes.


Assuntos
Oclusão Coronária/cirurgia , Vasos Coronários/cirurgia , Dissecação/métodos , Oclusão de Enxerto Vascular/cirurgia , Intervenção Coronária Percutânea , Stents , Idoso , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Feminino , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Masculino , Prognóstico , Sistema de Registros , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
18.
Prog Cardiovasc Dis ; 56(6): 583-95, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24838134

RESUMO

The implantation of a transcatheter heart valve (THV) through a balloon-expandable system played a major role in the early stages of transcatheter aortic valve replacement (TAVR). The technology consists of sewing a foldable biological cardiac valve inside a metallic stent frame, and then crimping the device into a balloon in order to implant the valve at the level of the aortic annulus through balloon inflation. The use of balloon-expandable valves underwent a rapid expansion in the years following the pioneering experience of 2002, and recent large multicenter trials and registries have confirmed the safety and efficacy of TAVR using balloon-expandable valves. The randomized Placement of Aortic Transcatheter Valves (PARTNER) trial showed both the superiority and non-inferiority of TAVR with the balloon-expandable Edwards-Sapien system compared to medical treatment (non-operable patients) and surgical aortic valve replacement (high risk patients), respectively. Balloon-expandable valves have been associated with excellent hemodynamic results (residual mean gradient <15 mm Hg in most cases), though residual paravalvular aortic regurgitation is frequent (trivial or mild in the majority of patients, moderate or severe in <10%). Valve durability studies with up to 5-year follow-up have shown maintained valve hemodynamics over time with only a minimal decrease in valve area and no increase in aortic regurgitation. Future improvements in the balloon-expandable THV technology such as implementing anti-paravalvular leak features (ex. Sapien 3 valve), and showing its efficacy for the treatment of non-high risk patients (ongoing PARTNER II trial) will probably lead to broader use in a lower risk population in the near future.


Assuntos
Estenose da Valva Aórtica/terapia , Valva Aórtica , Cateterismo Cardíaco/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Seleção de Pacientes , Desenho de Prótese , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
J Am Coll Cardiol ; 63(24): 2643-58, 2014 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-24681140

RESUMO

Significant mitral regurgitation (MR) is frequent in patients with severe aortic stenosis (AS). In these cases, concomitant mitral valve repair or replacement is usually performed at the time of surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has recently been considered as an alternative for patients at high or prohibitive surgical risk. However, concomitant significant MR in this setting is typically left untreated. Moderate to severe MR after aortic valve replacement is therefore a relevant entity in the TAVR era. The purpose of this review is to present the current knowledge on the clinical impact and post-procedural evolution of concomitant significant MR in patients with severe AS who have undergone aortic valve replacement (SAVR and TAVR). This information could contribute to improving both the clinical decision-making process in and management of this challenging group of patients.


Assuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Mitral/cirurgia , Animais , Estenose da Valva Aórtica/diagnóstico por imagem , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/tendências , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/tendências , Humanos , Insuficiência da Valva Mitral/diagnóstico por imagem , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia
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