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1.
Angiology ; 71(1): 48-55, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31315429

RESUMO

We searched PubMed, EMBASE, Cochrane Library, and Web of Science for studies using fractional flow reserve (FFR) to determine whether revascularization should be performed or deferred for patients with coronary stenosis and grey zone FFR. Meta-analysis was performed using the generic inverse variance method, and hazard ratios (HR) were synthesized with a random-effects model. Of 2766 records, 7 nonrandomized studies including 2683 patients were selected. The pooled results demonstrated, during a median follow-up of 32 months, that revascularization significantly reduced the risk of major adverse cardiac events (MACE; 7 studies: HR [95% confidence interval, CI]: 0.65 [0.45-0.93], P = .02) and target vessel revascularization (TVR; 4 studies: HR [95% CI]: 0.52 [0.36-0.76], P < .01). Whereas revascularization was not significantly superior in terms of all-cause death (3 studies: HR [95% CI]: 0.56 [0.26-1.22], P = .14), cardiac death (2 studies: HR [95% CI]: 0.57 [0.16-2.01], P = .38), myocardial infarction (MI; 4 studies: HR [95% CI]: 1.03 [0.26-4.03]), and all-cause death or MI (3 studies: HR [95% CI]: 0.66 [0.20-2.19], P = .50). Therefore, revascularization appeared to be superior to deferral for patients with grey zone FFR in MACE and TVR, while hard end points did not show such significance. This work was registered in PROSPERO (CRD42019118432).


Assuntos
Estenose Coronária/terapia , Reserva Fracionada de Fluxo Miocárdico , Revascularização Miocárdica , Tempo para o Tratamento , Idoso , Tomada de Decisão Clínica , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Estenose Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
2.
Int Heart J ; 60(5): 1154-1160, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31484855

RESUMO

In-stent neoatherosclerosis is an important problem after percutaneous coronary intervention. To explore the mechanisms and treatment of in-stent neoatherosclerosis, an animal model is needed. To avoid the disadvantages of current animal models, such as excessive use of X-rays and a high mortality rate, we attempted to develop an improved animal model. We explored a method that uses a short time interval to establish a rabbit model of in-stent neoatherosclerosis with a high survival rate and to evaluate its indicators. Sixty rabbits were divided into three equal groups: group A, the traditional method; group B, the standard intervention method; and group C, the improved method. In group C, we made two small incisions in each rabbit's neck, separated the common carotid, punctured it, and implanted a stent. The incision was then sutured. Four weeks later, we used optical coherence tomography (OCT) to scan all rabbits for neoatherosclerosis. We found no significant differences in OCT data between our new animal model and the traditional and interventional groups (P > 0.05). The technological success rate was higher in the new animal model (P < 0.001). We developed a new method to establish an animal model of neoatherosclerosis, which had similar results to the traditional and interventional methods.


Assuntos
Reestenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Stents/efeitos adversos , Tomografia de Coerência Óptica/métodos , Animais , Reestenose Coronária/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Modelos Animais de Doenças , Humanos , Masculino , Neointima/diagnóstico por imagem , Neointima/patologia , Variações Dependentes do Observador , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/mortalidade , Falha de Prótese , Coelhos , Distribuição Aleatória , Fatores de Risco , Estatísticas não Paramétricas , Taxa de Sobrevida
3.
Int Heart J ; 60(5): 1050-1060, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31484868

RESUMO

Edge restenosis has gained attention as a main cause of restenosis after first-generation drug-eluting stent (DES) implantation. The aim of this study was to assess the incidence of edge restenosis and identify the predictors of edge restenosis after second-generation DES implantation. Data were obtained from several postmarketing surveillance (PMS) studies on a cobalt-chromium everolimus-eluting stent (CoCr-EES; Xience V/PROMUS, Xience Prime, Xience Prime SV, and Xience Expedition SV), a second-generation DES, in Japan. Angiographic analysis was conducted at the baseline and after eight months on the following subsegments: in-stent region, proximal edge, and distal edge. Restenosis was defined as ≥ 50% diameter stenosis (DS) at follow-up. We used multivariate logistic regression (with lesions as a random effect) to compare the instances of restenosis between the proximal and the distal edges. Univariate and multivariate analyses of the risk factors for restenosis were performed for each subsegment. We analyzed 1,966 lesions in 1,687 patients. The restenosis rates at the in-stent region, proximal edge, and distal edge were 4.4%, 3.0%, and 1.1%, respectively. The risk of restenosis at the distal edge was significantly lower than that at the proximal edge, when adjusted for 13 variables. The predictors of restenosis were postprocedural % diameter stenosis (%DS), postprocedural reference diameter, ≥ 45° bending, stent overlap at the proximal edge, and postprocedural %DS at the distal edge. Our analysis of eight-month angiographic outcomes from CoCr-EES PMS demonstrated that postprocedural %DS is a major predictor of edge restenosis. Edge restenosis is more likely attributable to postprocedural angiographic results than to the patient's background.


Assuntos
Angiografia Coronária/métodos , Estenose Coronária/terapia , Stents Farmacológicos/efeitos adversos , Vigilância de Produtos Comercializados , Desenho de Prótese , Sirolimo/farmacologia , Fatores Etários , Idoso , Angioplastia Coronária com Balão/métodos , Angioplastia Coronária com Balão/mortalidade , Cromo , Cobalto , Estudos de Coortes , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/epidemiologia , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Análise de Falha de Equipamento , Feminino , Hospitais Universitários , Humanos , Incidência , Japão , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Análise de Sobrevida , Resultado do Tratamento
4.
Int J Cardiovasc Imaging ; 35(12): 2147-2155, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31359232

RESUMO

Tortuous coronary lesions are associated with adverse outcomes after implantation of bare metal or first-generation drug-eluting stents (DESs). We investigated the impact of lesion angle on vessel wall injuries and stent apposition as assessed by optical coherence tomography (OCT) after second- and newer-generation DES implantation. We investigated 95 de novo lesions treated with a single DES (62 platinum-chromium everolimus-eluting stents and 33 bioresorbable-polymer sirolimus-eluting stents). Post-intervention OCT findings were compared between angled lesions (≥ 45°; n = 33) and non-angled lesions (< 45°; n = 62). The 12-month clinical outcomes were also compared between the groups. Cross-sectional OCT analysis revealed that compared to non-angled lesions, angled ones had a significantly higher incidence of intra-stent dissection around the centre of the angle (19.7% vs. 10.8%, p = 0.01) and incomplete stent apposition (ISA) in the distal and proximal sub-segments (10.0% vs. 4.1%, p = 0.002; 15.3% vs. 7.9%, p < 0.001, respectively). Strut-based analysis also showed that angled lesions demonstrated a higher rate of malapposed strut in the distal and proximal sub-segments (3.0% vs. 0.9%, p < 0.001; 4.3% vs. 1.8%, p < 0.001, respectively). The 12 month clinical outcomes were comparable between the groups. Compared to non-angled lesions, angled coronary lesions were associated with a higher incidence of intra-stent dissection and ISA on post-intervention OCT after implantation of second- and newer-generation DESs.


Assuntos
Doença da Artéria Coronariana/terapia , Vasos Coronários/diagnóstico por imagem , Stents Farmacológicos , Intervenção Coronária Percutânea/instrumentação , Tomografia de Coerência Óptica , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Desenho de Prótese , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
5.
Int J Cardiovasc Imaging ; 35(9): 1733-1743, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31073698

RESUMO

Vasodilator-stress CT perfusion imaging in addition to CT coronary angiography (CTCA) may provide a single-test alternative to nuclear stress testing, commonly used to assess hemodynamic significance of stenosis. Another alternative is fractional flow reserve (FFR) calculated from cardiac CT images. We studied the concordance between these two approaches and their relationship to outcomes. We prospectively studied 150 patients with chest pain, who underwent CTCA and regadenoson CT. CTCA images were interpreted for presence and severity of stenosis. Fused 3D displays of subendocardial X-ray attenuation with coronary arteries were created to detect stress perfusion defects (SPD) in each coronary territory. In patients with stenosis > 25%, CT-FFR was quantified. Significant stenosis was determined by: (1) combination of stenosis > 50% with an SPD, (2) CT-FFR ≤ 0.80. Patients were followed-up for 36 ± 25 months for death, myocardial infarction or revascularization. After excluding patients with normal arteries and technical/quality issues, in final analysis of 76 patients, CTCA depicted stenosis > 70% in 13/224 arteries, 50-70% in 24, and < 50% in 187. CT-FFR ≤ 0.80 was found in 41/224 arteries, and combination of SPD with > 50% stenosis in 31/224 arteries. Inter-technique agreement was 89%. Despite high incidence of abnormal CT-FFR (30/76 patients), only 7 patients experienced adverse outcomes; 6/7 also had SPDs. Only 1/9 patients with CT-FFR ≤ 0.80 but normal perfusion had an event. Fusion of CTCA and stress perfusion can help determine the hemodynamic impact of stenosis in one test, in good agreement with CT-FFR. Adding stress CT perfusion analysis may help risk-stratify patients with abnormal CT-FFR.


Assuntos
Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Reserva Fracionada de Fluxo Miocárdico , Hemodinâmica , Imagem Tridimensional/métodos , Imagem de Perfusão do Miocárdio/métodos , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Adulto , Idoso , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Estenose Coronária/mortalidade , Estenose Coronária/fisiopatologia , Estenose Coronária/terapia , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Vasodilatadores/administração & dosagem
6.
Int J Cardiovasc Imaging ; 35(4): 579-586, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30929102

RESUMO

The purpose of this observational study was to investigate the feasibility, initial safety, and efficacy of the SeQuent® Please DCB (B. Braun Melsungen, Germany) for patients with de novo coronary lesions in vessels exceeding 3.0 mm in a consecutive series of all comer percutaneous coronary intervention. A total of 120 patients (135 lesions) with de novo coronary lesions in vessels ≥ 3.0 mm treated with DCB were enrolled in this single-centre prospective observational study. The primary endpoint was target lesion failure (TLF), a composite endpoint of cardiac death, target vessel-myocardial infarction (TV-MI), and clinically driven target vessel revascularization (TLR) at 12 months. Safety endpoints included cardiac death, TV-MI, and definite target vessel thrombosis. 45.9% of the lesions were classified as complex (type B2/C). The reference vessel diameter was 3.09 ± 0.31 mm measured via quantitative coronary angiography analysis. Coronary dissections occurred in 42 patients (35.0%; Type A-B 14.1%; Type C 19.1%; Type D: 1.6%), two of which [1.6%; (type D dissection)] underwent bail-out stent implantation. 12-month follow-up was completed in 100% patients. The 12-month incidence of TLF was 3.4%. The clinically driven TLR occurred in four patients (3.4%). The incidence of TLR was low in patients without any detectable dissections, similar to those with dissections (3.8% vs. 2.5%; p = 0.146). No patient suffered cardiac death, TV-MI, or target vessel thrombosis. The study shows the feasibility, initial safety, and efficacy of coronary intervention using SeQuent® Please DCB for the treatment of patients with de novo lesion in vessels exceeding 3 mm. The study highlights that the coronary dissection (Type A-C) post DCB treatment occurs frequently but is safe at follow up.


Assuntos
Cateteres Cardíacos , Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Doença da Artéria Coronariana/cirurgia , Estenose Coronária/cirurgia , Paclitaxel/administração & dosagem , Intervenção Coronária Percutânea/instrumentação , Idoso , Fármacos Cardiovasculares/efeitos adversos , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Paclitaxel/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
7.
J Cardiovasc Med (Hagerstown) ; 20(4): 210-214, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30720634

RESUMO

BACKGROUND: Although some previous studies assessed characteristics and outcome of patients with suspected no-ST-segment elevation acute myocardial infarction (NSTEMI), but no obstructive coronary artery disease (NOCAD) at angiography, most were performed before high-sensitivity troponin assays were available. METHODS AND RESULTS: We reviewed data of patients admitted to our hospital with a suspicion of NSTEMI between 2013 and 2016. Patients with previous evidence of CAD (except those with fully percutaneous coronary revascularization) were excluded. Patients were divided into those with obstructive CAD and those with NOCAD (no coronary stenosis ≥50% in any vessel). The final population included 430 patients - 317 (73.7%) with CAD and 113 (26.3%) with NOCAD. Compared with CAD, NOCAD patients were younger, more frequently women, and had a lower prevalence of cardiovascular risk factors and peak troponin level. In-hospital death or myocardial infarction occurred in eight (2.5%) and two (1.8%) patients in CAD and NOCAD patients, respectively (P = 1.00). A lower left ventricular ejection fraction (LVEF) and left main CAD were the only independent predictors of in-hospital death and death or myocardial infarction. CONCLUSIONS: Among patients with suspect NSTEMI, about one-fourth showed NOCAD at angiography in the era of elevated sensitivity troponin assays and when excluding patients with largely predictable obstructive CAD. Higher troponin levels were associated with obstructive CAD, but a lower LVEF and left main disease only predicted in-hospital outcome in this population.


Assuntos
Estenose Coronária/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Troponina/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Estenose Coronária/fisiopatologia , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Admissão do Paciente , Valor Preditivo dos Testes , Prevalência , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Roma/epidemiologia , Volume Sistólico , Regulação para Cima , Função Ventricular Esquerda
8.
Trials ; 20(1): 84, 2019 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-30691507

RESUMO

BACKGROUND: Even in the current drug-eluting stent era, revascularization for coronary stenosis with fractional flow reserve (FFR) between 0.75 and 0.80, the so-called "gray zone," is a matter of debate. Previous studies have reported conflicting results regarding outcomes of revascularization versus deferral for coronary stenosis when FFR values are in the gray zone, but these studies have had differing designs and populations. We therefore will investigate whether medical therapy plus percutaneous coronary intervention (PCI) is superior to medical therapy alone in reducing major cardiovascular events in patients presenting with coronary stenosis with gray zone FFR values. METHODS/DESIGN: This is a prospective, multicenter, open-label, parallel group, randomized, controlled, superiority study. A total of 410 eligible participants will be recruited and randomized to either the medical therapy plus PCI group or the medical therapy alone group. The primary endpoint is 1-year major adverse cardiac events (MACEs), defined as a combined endpoint of all-cause death, nonfatal myocardial infarction (MI), or unplanned target vessel revascularization (TVR). Secondary endpoints include MACE at 2 and 5 years. Moreover, each individual component of the primary endpoint, cardiovascular death, target vessel-related and non-target vessel-related MI, all MI, clinically driven TVR or non-TVR, all revascularization, stent thrombosis, and angina symptom status will be evaluated at 1, 2, and 5 years. DISCUSSION: This is the first prospective, multicenter, randomized, controlled study to investigate the superiority of medical therapy plus PCI over medical therapy by itself in reducing major cardiovascular events in patients presenting with coronary stenosis with "gray zone" FFR values. The results will help interventional cardiologists in making revascularization decisions regarding coronary stenosis with gray zone FFR values. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry, UMIN000031526 . Registered on 1 March 2018.


Assuntos
Angina Estável/terapia , Fármacos Cardiovasculares/uso terapêutico , Estenose Coronária/terapia , Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Angina Estável/diagnóstico por imagem , Angina Estável/mortalidade , Angina Estável/fisiopatologia , Cateterismo Cardíaco , Fármacos Cardiovasculares/efeitos adversos , Terapia Combinada , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Estenose Coronária/fisiopatologia , Humanos , Japão , Estudos Multicêntricos como Assunto , Intervenção Coronária Percutânea/efeitos adversos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do Tratamento
9.
Anatol J Cardiol ; 21(2): 83-90, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30694800

RESUMO

OBJECTIVE: Intravascular ultrasound (IVUS) has developed as a preferable choice for optimizing the stenting procedures mainly because it will have good access to vessel size, lesion length, or severity accurately. However, it still remains unclear about the benefits of IVUS guidance in drug-eluting stent (DES) implantation for patients with unprotected left main coronary artery (ULMCA) stenosis. The aim of the present study was to evaluate the clinical outcomes with respect to IVUS-guided DES implantation for these patients. METHODS: A total of 336 consecutive patients from December 2010 to December 2015 were enrolled in the study. The patients were then randomly assigned into two groups: IVUS-guided group (n=167) and control group (n=169). The primary endpoint was the incidence of composite major adverse cardiac events (MACEs), including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). The risk of stent thrombosis (ST) was chosen as the safety endpoint. RESULTS: After a 1-year follow-up, the occurrence of composite MACE in the IVUS-guided group was significantly lower than that in the control group (13.2% vs. 21.9%, p=0.031), which might mainly result from the significant reduction in the risk of cardiac death (1.8% vs. 5.9%, p=0.048). Dramatically, the risk of MI did not differ significantly between the two groups (11.4% vs. 13.6%, p=0.478), though a tended reduction in TVR was observed under IVUS guidance (4.2% vs. 8.9%, p=0.068). There was no statistical significance between the two groups with respect to the risk of target lesion revascularization (IVUS-guided vs. control: 1.2% vs. 3.0%, p=0.239) and ST (IVUS-guided vs. control: 1.2% vs. 3.0%, p=0.246). CONCLUSION: The possible feasibility of IVUS-guided DES implantation for patients with ULMCA stenosis was supported by the present study. Larger and more powerful randomized trials were still warranted to research the whole benefits of IVUS guidance for these patients.


Assuntos
Estenose Coronária/cirurgia , Vasos Coronários , Stents Farmacológicos , Idoso , China , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Sobrevida , Resultado do Tratamento , Ultrassonografia de Intervenção
11.
Catheter Cardiovasc Interv ; 93(1): 71-78, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30232838

RESUMO

AIM AND OBJECTIVE: We sought to investigate and compare outcomes 2 years after Hybrid-stenting with bioresorbable vascular scaffolds (BVS) and contemporary metallic drug-eluting stents (DES) within the same coronary lesion versus BVS alone. METHODS: Between 11/2012 and 7/2015 at our institution, 134 (33.2%) were treated with Hybrid-stenting for complex or long coronary lesions, 270 patients were treated by BVS alone. The primary outcome of interest was target lesion failure (TLF) at 2-years of follow-up. RESULTS: Patients treated by Hybrid-stenting were more frequently men (80% vs. 70%, p = 0.04) had extensive multivessel disease (84% vs. 71%, p < 0.01) including more complex (89% vs. 52%, p < 0.01) and longer lesions (28.9 mm vs 16.4 ± mm, p < 0.01) resulting in longer treated segments (47.3 mm vs 21.5 mm, p < 0.01) and more residual in-segment stenosis (12.3% vs 8.5%, p < 0.01) compared to BVS alone patients. At 2 years, cumulative incidence of TLF was 9.7% of Hybrid-stenting patients and 11.5% of BVS alone patients (p = 0.62), myocardial infarction (3.0% vs 4.1%, p = 0.59) and mortality (1.5% vs 4.1%, p = 0.17), respectively. Target lesion revascularization occurred in 9 Hybrid-stenting patients (2 located in DES) and in 20 BVS alone patients, cumulative incidence 6.7% vs. 7.4% (p = 0.80). Chronic kidney disease and residual in-segment stenosis >30% were identified as independent predictors of TLF at 2-years. CONCLUSION: Despite differences in clinical and angiographic profile, Hybrid-stenting performed similar to BVS alone at 2 years after percutaneous coronary intervention.


Assuntos
Implantes Absorvíveis , Angioplastia Coronária com Balão/instrumentação , Doença da Artéria Coronariana/terapia , Estenose Coronária/terapia , Stents Farmacológicos , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/mortalidade , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Feminino , Humanos , Masculino , Metais , Pessoa de Meia-Idade , Desenho de Prótese , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
12.
Ann Thorac Surg ; 107(4): 1166-1173, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30444991

RESUMO

BACKGROUND: To minimize aortic manipulation and maximize use of arterial conduits are aims of modern coronary surgery. METHODS: From March 2012 to October 2016, 890 consecutive patients with multivessel coronary disease underwent isolated coronary operations using both internal thoracic arteries (ITAs). In 205 (23%; mean age, 67.6 ± 9.2 years), the right ITA was proximally transected and used as a free graft, while its in situ stump was elongated with a saphenous vein graft. The new arteriovenous I conduit was directed to the inferolateral cardiac wall. Operative data and early outcomes of these patients (I group) were compared with the remaining 685 patients (control [C] group). Early and late outcomes were also compared in 184 pairs identified with propensity score matching. RESULTS: Between the I and C groups there was no significant difference in expected operative risk (European System for Cardiac Operative Risk Evaluation II, p = 0.28), although diseased ascending aorta (p < 0.0001) and critical preoperative state (p = 0.027) were more frequent in the I group. Despite a higher number of coronary anastomoses (mean, 4 ± 0.9 vs 3.7 ± 1, p < 0.0001), cardiopulmonary bypass time was shorter in the I group both in overall (86.7 ± 23.7 vs 105.7 ± 34.2 minutes, p < 0.0001) and matched series (86.8 ± 24.1 vs 108.8 ± 31.9 minutes, p < 0.0001). In-hospital mortality (1% vs 1.9%, p = 0.54) and the rates of postoperative complications were similar. During the follow-up period, no intergroup difference was found in matched patients in the nonparametric estimates of freedom from all-cause death (p = 0.39) and major adverse cardiac and cerebrovascular events (p = 0.44). CONCLUSIONS: Surgery using this arteriovenous I conduit is safe, minimizes aortic manipulation, shortens cardiopulmonary bypass time, and aids complete revascularization.


Assuntos
Fístula Anastomótica/prevenção & controle , Ponte de Artéria Coronária/métodos , Estenose Coronária/cirurgia , Mortalidade Hospitalar , Anastomose de Artéria Torácica Interna-Coronária/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Angiografia Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Feminino , Seguimentos , Humanos , Itália , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular/fisiologia
13.
Angiology ; 70(4): 337-344, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30286625

RESUMO

It was a randomized trial, and 308 patients undergoing revascularization were randomly assigned: 155 to off-pump coronary artery bypass (OPCAB) and 153 to on-pump coronary artery bypass (ONCAB). End points were freedom from death, myocardial infarction, revascularization, and cerebrovascular accidents. The rates for 10-year, event-free survival for ONCAB versus OPCAB were 69.6% and 64%, (hazard ratio [HR]: 0.88; 95% confidence interval [CI] 0.86-1.02; P = .41), respectively. Adjusted Cox proportional hazard ratio was similar (HR: 0.92; 95% CI 0.61-1.38, P = .68). A difference occurred between the duration of OPCAB and ONCAB, respectively (4.9 ± 1.5 vs 6.6 ± 1.1 h, P < .001). Statistical differences occurred between OPCAB and ONCAB in the length of intensive care unit (ICU) stay (20 ± 2.5 vs 48 ± 10 hours, P < .001), time to extubation (5.5 ± 4.2 vs 10.2 ± 3.5 hours, P < .001), hospital stay (6.7 ± 1.4 vs 9.2 ± 1.3 days, P < .001), higher incidence of atrial fibrillation (AF; 33 vs 5 patients, P < .001), and blood requirements (46 vs 64 patients, P < .001). Grafts per patient was higher in ONCAB (3.15 vs 2.55 grafts, P < .001). No difference existed between the groups in primary composite end points at 10-year follow-up. Although OPCAB surgery was related to a lower number of grafts and higher incidence of AF, it had no effects related to long-term outcomes.


Assuntos
Ponte Cardiopulmonar , Ponte de Artéria Coronária sem Circulação Extracorpórea , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Estenose Coronária/cirurgia , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Intervalo Livre de Progressão , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
14.
Thorac Cardiovasc Surg ; 67(6): 484-487, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30071564

RESUMO

We studied myocardial protection during coronary artery bypass graft surgery using low-volume cardioplegia (Cardioplexol) and minimal extracorporeal circulation (MECC) for different types of coronary artery diseases. In total, 426 consecutive patients were included and divided into four groups: those with left main stem stenosis (n = 45), those with three-vessel disease (n = 200), those with both (n = 141), and those with neither (n = 40). The peak postoperative myocardial markers and 30-day mortality were analyzed. Both myocardial markers and 30-day mortality were significantly elevated in patients with isolated main stem stenosis. We conclude that the use of low-volume cardioplegia and MECC is safe. However, patients with underlying isolated left main stem stenosis might be less protected.


Assuntos
Soluções Cardioplégicas/administração & dosagem , Ponte de Artéria Coronária , Estenose Coronária/cirurgia , Circulação Extracorpórea/métodos , Parada Cardíaca Induzida/métodos , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Compostos de Potássio/administração & dosagem , Biomarcadores/sangue , Soluções Cardioplégicas/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Estenose Coronária/sangue , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Creatina Quinase Forma MB/sangue , Bases de Dados Factuais , Circulação Extracorpórea/efeitos adversos , Circulação Extracorpórea/mortalidade , Feminino , Parada Cardíaca Induzida/efeitos adversos , Parada Cardíaca Induzida/mortalidade , Humanos , Masculino , Traumatismo por Reperfusão Miocárdica/sangue , Traumatismo por Reperfusão Miocárdica/diagnóstico , Traumatismo por Reperfusão Miocárdica/mortalidade , Compostos de Potássio/efeitos adversos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Troponina T/sangue
15.
Clin Res Cardiol ; 108(2): 175-184, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30051181

RESUMO

AIMS: Percutaneous coronary intervention (PCI) of unprotected distal left main stenosis (UDLM) is increasingly performed as an alternative to surgical treatment. The optimal strategy for stenting in this setting is still a matter of debate. Therefore, this analysis investigated the long-term clinical outcome of a single- versus a double-stenting strategy for treatment of UDLM. METHODS AND RESULTS: From a large registry, 867 consecutive patients with UDLM undergoing either single or double stenting with drug-eluting stents (DES) were identified. Follow-up was up to 10 (median 3.1, interquartile range 1.1-5.3) years. Primary endpoint was MACE consisting of all-cause death, myocardial infarction, or target lesion re-intervention (TLR). Secondary clinical endpoints included these single endpoints and stent thrombosis. MACE occurred in 41.5% after single and in 49.0% after double stenting (P = 0.03). TLR was lower after single (17.4%) as compared to double stenting (27.2%; P < 0.01). Between single and double stenting, there were no significant differences for death (26.4 versus 23.3%; P = 0.31), death or myocardial infarction (29.1 versus 27.2%; P = 0.55), or definite/probable stent thrombosis (1.3 versus 2.1%; P = 0.42). CONCLUSIONS: Compared with single stenting, double stenting was associated with a significantly higher long-term risk of MACE. This was driven by a higher incidence of TLR, whereas the risk of death, MI, or stent thrombosis was similar between the two strategies.


Assuntos
Estenose Coronária/cirurgia , Vasos Coronários/cirurgia , Stents Farmacológicos , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Idoso , Causas de Morte/tendências , Angiografia Coronária , Estenose Coronária/diagnóstico , Estenose Coronária/mortalidade , Vasos Coronários/diagnóstico por imagem , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento
16.
Catheter Cardiovasc Interv ; 93(1): 1-8, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30208254

RESUMO

OBJECTIVES: The aim was to assess the extent of coronary artery disease and revascularization using baseline SYNTAX Score (bSS) and residual SYNTAX Score (rSS) in patients with cardiogenic shock (CS) secondary to ST-segment elevation myocardial infarction (STEMI). The prognostic impact of SYNTAX Score (SS) was evaluated and assessed for additive value over clinical risk scores. BACKGROUND: bSS and rSS have been proven to be useful in risk stratification in stable coronary artery disease as well as in acute coronary syndromes, but they have not been studied in STEMI related CS. METHODS: Patients from a multinational prospective study of CS were analyzed. The study population was divided into tertiles according to bSS. The Cox regression and receiver operating characteristic (ROC) curves were used to assess the predictive power of SS. RESULTS: Of the 61 studied patients, 85% were male and the mean age was 67 years. Median bSS was 22 (15-32) and rSS 7 (0-13). Ninety-day mortality was 43%. bSS had negative prognostic value in multivariable analysis (HR 1.06, 95% CI 1.01-1.10). However, additive value over clinical risk scores was limited. rSS was not associated with mortality, whereas post-percutaneous coronary intervention (PCI) TIMI flow 3 of infarct-related artery (IRA) predicted better survival. CONCLUSIONS: In STEMI related CS, the added value of bSS and rSS over clinical assessment and risk scores is limited. Our results suggest that while immediate PCI in order to restore blood flow to the IRA is essential, deferring the treatment of residual lesions does not seem to be associated with worse prognosis.


Assuntos
Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Choque Cardiogênico/etiologia , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/terapia , Estenose Coronária/complicações , Estenose Coronária/mortalidade , Estenose Coronária/terapia , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Índice de Gravidade de Doença , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Fatores de Tempo , Resultado do Tratamento
17.
Circulation ; 139(3): 325-333, 2019 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-30586724

RESUMO

BACKGROUND: New-generation drug-eluting stents offer the potential for enhanced late outcomes in comparison with early generation drug-eluting stents. However, assessment of extended long-term outcomes for these devices is lacking, especially regarding the comparison between new-generation drug-eluting stents with biodegradable or permanent polymers. The aim of this study is to compare the efficacy and safety of biodegradable polymer-based sirolimus-eluting stents (BP-SES; Yukon Choice PC) versus permanent polymer-based everolimus-eluting stents (PP-EES; Xience) versus early generation permanent polymer-based sirolimus-eluting stents (PP-SES; Cypher) at 10-year follow-up. METHODS: Overall, 2603 patients were randomized to treatment with BP-SES (n=1299), PP-EES (n=652), or PP-SES (n=652). The primary end point of this analysis was major adverse cardiac event, the composite of death, myocardial infarction, or target lesion revascularization. The main secondary end point of interest was definite/probable stent thrombosis. Follow-up at 10 years was available in 83% of the study patients. RESULTS: The 10-year incidence of major adverse cardiac event (BP-SES 47.7% versus PP-EES 46.0% versus PP-SES 54.9%, P=0.003) and mortality (BP-SES 31.8% versus PP-EES 30.3% versus PP-SES 37.2%, P=0.02) was different among the groups. Definite/probable stent thrombosis was not significantly different among the groups (BP-SES 1.8% versus PP-EES 2.5% versus PP-SES 3.7%, P=0.09). Definite stent thrombosis was significantly different among the groups (BP-SES 1.1% versus PP-EES 0.8% versus PP-SES 2.4%, P=0.03). There were no significant differences between BP-SES and PP-EES. CONCLUSIONS: In this unique long-term outcome analysis, BP-SES and PP-EES showed comparable clinical outcomes out to 10 years. PP-SES had higher rates of major adverse cardiac events and definite stent thrombosis. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00598676.


Assuntos
Implantes Absorvíveis , Fármacos Cardiovasculares/administração & dosagem , Doença da Artéria Coronariana/terapia , Estenose Coronária/terapia , Stents Farmacológicos , Intervenção Coronária Percutânea/instrumentação , Polímeros/química , Sirolimo/administração & dosagem , Idoso , Fármacos Cardiovasculares/efeitos adversos , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Trombose Coronária/etiologia , Trombose Coronária/mortalidade , Everolimo/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Desenho de Prótese , Medição de Risco , Fatores de Risco , Sirolimo/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
18.
J Am Coll Cardiol ; 72(22): 2732-2743, 2018 12 04.
Artigo em Inglês | MEDLINE | ID: mdl-30497559

RESUMO

BACKGROUND: The value of fractional flow reserve (FFR) evaluation of coronary artery stenosis in coronary artery bypass grafting (CABG) is uncertain, and stenosis assessments usually rely on visual estimates of lesion severity. OBJECTIVES: This randomized clinical trial evaluated graft patency and clinical outcome after FFR-guided CABG versus angiography-guided CABG. METHODS: A total of 100 patients referred for CABG were randomly assigned to FFR-guided or angiography-guided CABG. Based on the coronary angiogram, a heart team made a graft plan for all patients, and FFR evaluations were performed. In FFR-guided CABG, coronary lesions with FFR >0.80 were deferred, and a new graft plan was designed accordingly, whereas the surgeon was blinded to the FFR values in patients who underwent angiography-guided CABG. The primary endpoint was graft failure in the percentage of all grafts after 6 months. RESULTS: Angiographic follow-up at 6 months was available for 72 patients (39 vs. 33 in the FFR-guided and angiography-guided groups, respectively). Graft failures of all grafts were similar in both groups (16% vs. 12%; p = 0.97). Rates of death, myocardial infarction, and stroke were also similar in the study groups, and no difference was seen in revascularization before angiographic follow-up. After 6 months, deferred lesions (n = 24) showed a significant reduction in mean FFR from index to follow-up (0.89 ± 0.05 vs. 0.81 ± 0.11; p = 0.002). Index FFR did not influence graft patency. CONCLUSIONS: FFR-guided CABG had similar graft failure rates and clinical outcomes as angiography-guided CABG. However, FFR was reduced significantly after 6 months in deferred lesions. (Fractional Flow Reserve Versus Angiography Randomization for Graft Optimization [FARGO]; NCT02477371).


Assuntos
Angiografia Coronária/métodos , Ponte de Artéria Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Idoso , Angiografia Coronária/efeitos adversos , Angiografia Coronária/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Estenose Coronária/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Estudos Prospectivos , Método Simples-Cego , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade
19.
JACC Cardiovasc Interv ; 11(24): 2467-2476, 2018 12 24.
Artigo em Inglês | MEDLINE | ID: mdl-30573057

RESUMO

OBJECTIVES: The authors sought to investigate the impact of diabetes mellitus (DM) on outcomes following contemporary drug-eluting stent (DES) implantation in the BIONICS (BioNIR Ridaforolimus Eluting Coronary Stent System in Coronary Stenosis) trial. BACKGROUND: Patients with DM are at increased risk for adverse events following percutaneous coronary intervention (PCI). METHODS: A prospective, multicenter, 1:1 randomized trial was conducted to evaluate in a noninferiority design the safety and efficacy of ridaforolimus-eluting stents versus zotarolimus-eluting stents among 1,919 patients undergoing PCI. Randomization was stratified to the presence of medically treated DM, and a pre-specified analysis compared outcomes according to the presence or absence of DM up to 2 years. RESULTS: The overall prevalence of DM was 29.1% (559 of 1,919). DM patients had higher body mass index, greater prevalence of hyperlipidemia and hypertension, and smaller reference vessel diameter. One-year target lesion failure (cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization) was significantly higher among diabetic patients (7.8% vs. 4.2%; p = 0.002), mainly due to higher target lesion revascularization (4.5% vs. 2.0%; p = 0.002). Rates of cardiac death, myocardial infarction, and stent thrombosis did not statistically vary. Among 158 patients undergoing 13-month angiographic follow-up, restenosis rates were 3 times higher in diabetic patients compared with nondiabetic patients (15.2% vs. 4.7%; p = 0.01). Clinical and angiographic outcomes were similar between ridaforolimus-eluting stent- and zotarolimus-eluting stent-treated patients. CONCLUSIONS: Despite advances in interventional therapies, and the implementation of new-generation DES, diabetic patients still have worse angiographic and clinical outcomes compared with nondiabetic patients undergoing PCI.


Assuntos
Fármacos Cardiovasculares/administração & dosagem , Doença da Artéria Coronariana/terapia , Estenose Coronária/terapia , Diabetes Mellitus/epidemiologia , Stents Farmacológicos , Intervenção Coronária Percutânea/instrumentação , Sirolimo/análogos & derivados , Idoso , Fármacos Cardiovasculares/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Reestenose Coronária/epidemiologia , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Trombose Coronária/epidemiologia , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Prevalência , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Método Simples-Cego , Sirolimo/administração & dosagem , Sirolimo/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
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