The importance of organic carbon as a coadjutant in the transport of pollutants.

Dissolved organic carbon (DOC) is a physicochemical parameter widely used in the evaluation of surface water quality; however, its role as an agent of transport and transference of pollutants sometimes is still disregarded. The heterogeneous composition of DOC, predominantly composed of humin, humic and fulvic acids, renders it an inherent capacity to bind to organic and inorganic pollutants. This is an important feature when the knowledge of present and future conditions of aquatic environments is of concern. Some authors concluded that DOC is a controlling agent of mobility of metals, phosphorus, herbicides, and pesticides, among others. Nevertheless, some physical and chemical conditions in the water column and in the sediment can immobilize the contaminants and make the DOC less soluble, which will hamper the formation of DOC-pollutant complexes. This mini review is intended to present the importance of DOC quantification and some information on its association with water contaminants, which could render them unavailable for uptake.

Adaptive monitoring approach to assess dissolved organic matter dynamics during rainfall events.

Rainfall events induce water quality transformation in river systems influenced by the watershed land use and hydrology dynamics. In this context, an adaptive monitoring approach (AMA) is used to assess non-point sources (NPS) of pollution events, through dissolved organic matter (DOM) contribution. The case study is a monitoring site in a semi-urban watershed characterized by NPS contribution. An integrated quali-quantitative method for DOM based on dissolved organic carbon (DOC) content, spectroscopic techniques of excitation-emission fluorescence (EEF), and UV-visible absorbance is proposed. The results indicate a mix of allochthonous and autochthonous DOM characteristics from NPS sources associated to vegetation area influence (A285/DOC of 15.43 L (g cm)-1 and SUVA254 of 2.11 L (mg m)-1). The EEF signals showed more humic-like than protein-like characteristics with peaks A and C (approximately 5.72 r.u.) more intense than peaks B, T1, and T2 (approximately 4.33 r.u.), indicating NPS from the soil leachate. The absorbance ratio values indicate a mix of organic compounds with greater proportion of refractory characteristics with high aromaticity and molecular weight (approximately A300/A400 of 4.15 and A250/A365 of 4.48), associated with the surface wash-off of accumulated residual and subsurface soil erosion, which contribute to complex organic matter structures. The fluorescence indexes, overall, indicated allochthonous sources with intermediate humic characteristics (FI ≈ 1.43, BIX ≈ 0.65, and HIX ≈ 7.98). The proposed integrated optical property strategy represents an opportunity for better understanding of DOM dynamic assessment for identifying potential mitigation techniques for organic pollution control and improving water quality conditions.

E/e` ratio is superior to speckle tracking for detecting elevated left ventricular end-diastolic pressure in patients with coronary artery disease and preserved ejection fraction.

BACKGROUND: A weak correlation has been reported between left ventricular filling pressures and the traditional echocardiographic tools for the evaluation of diastolic function in patients with coronary artery disease (CAD) and preserved left ventricular ejection fraction (LVEF). On the other hand, studies that compared invasive measurements with speckle tracking echocardiography have shown promising results, but they were not exclusively targeted on this specific population. METHODS AND RESULTS: Immediately before the left heart catheterization, a comprehensive two-dimensional Doppler echocardiography and speckle tracking analysis was prospectively performed in outpatients referred for coronary angiography. Left ventricular end-diastolic pressure (LVEDP) was measured before any contrast exposure. Eighty-one patients with coronary artery disease were studied, and the group with high LVEDP (n = 40) showed increased left atrial volume index (22 ± 6 mL/m2 vs 26 ± 8.26 mL/m2 , P = 0.04), E-wave velocity (65 ± 15 cm/s vs 78 ± 20 cm/s, P = 0.02), E/e` (average) ratio (8.14 ± 2.0 vs 11.54 ± 2.7, P = 0.03), and E/global circumferential strain rate E peak ratio (E/GCSRE ) (39 cm vs 46 cm, P < 0.01). There was a positive correlation between LVEDP and E/e` (ρ = 0.56; P = 0.03), and between LVEDP and E/GCSRE ratio (ρ = 0.43; P < 0.01). The area under the receiver operating characteristics (ROC) curve was 0.83 and 0.73, respectively (P < 0.05). E/e` and E/GCSRE were both independent predictors of elevated LVEDP (P < 0.05), with a higher C-statistic for the model including E/e` (0.89 vs 0.85). CONCLUSION: The E/e` ratio was able to identify elevated LVEDP in CAD patients with preserved LVEF with more accuracy than the E/GCSRE ratio.

Water quality dynamic during rainfall episodes: integrated approach to assess diffuse pollution using automatic sampling.

Diffuse pollution caused by rainfall events potentially affects water quality in rivers and, therefore, must be investigated in order to improve water quality planning and management recovery strategies. For these, a quali-quantitative approach was used to monitor the water quality parameters in a river located in a semi-urban watershed area based upon automatic sampling. Thirteen water quality parameters were measured during five rainfall events. Events ranged from 2.3 to 56.8 mm and water peak flows from 3.3 to 4.5 m3/s. The pollutographs measured showed a standard pattern for total suspended solids (TSS). However, for the other chemical parameters, as total phosphorous (TP) and dissolved organic carbon (DOC), the dilution effects were more evident. It was possible to observe the rainfall influence mainly for physical parameters indicating a mass transport pattern for diffuse pollutants, which increased, for example, the amount of TSS in the river. Furthermore, hydrological characteristics were relevant considering the pollutant behavior. Antecedent dry periods, ranging from 1.3 days to 21.4 days, and critical time, from 2.0 to 10.4 h, are determinants to evaluate non-traditional water quality impacts in the river. In general, each rainfall episode has its own characteristics, which produces distinct mass contribution and temporal behavior, being challenging in making generalization. Therefore, the results indicate that diffuse pollution has to be considered to establish future decision-making strategies to water resources management.

Scaling-up of the adsorption process of ammonia nitrogen onto expanded vermiculite using fixed-bed columns.

Expanded vermiculite was used as an adsorbent to remove ammonia nitrogen from landfill leachate. Bench and pilot-scale adsorption experiments were performed with leachate collected from a closed sanitary landfill located in Curitiba, southern Brazil. At the bench-scale, two different heights of vermiculite and three different flow rates were tested using a fixed-bed column. These tests produced an average uptake capacity of 33.4 mg g-1 for the ammonia nitrogen concentration of 2,560 mg L-1. The Yan model was used to determine the breakthrough and the exhaustion times due to the best fit of the data to this model. At the pilot-scale, the flow rate was determined from the shortest length of the mass transfer zone obtained from bench-scale experiments. Tests were performed using one stainless-steel column filled with 26.2 kg of expanded vermiculite, which resulted in a bed height of 1.6 m. A leachate flow rate of approximately 350 L d-1 was applied to achieve the required contact time of 8.3 h. At this scale, an average uptake capacity of 18.1 mg g-1 was obtained for the ammonia nitrogen concentration of 1,193 mg L-1. It is worth mentioning that the flow rate and the concentration of the adsorbate in the feeding solution are fundamental to improve the operational time of the fixed-bed column. The main goal of this research was the determination of operating conditions to scale-up the adsorption process of ammonia nitrogen onto expanded vermiculite. The contact time was a key parameter to reach this goal.

Left atrial strain as a predictor of left ventricular filling pressures in coronary artery disease with preserved ejection fraction: a comprehensive study with left ventricular end-diastolic and pre-atrial contraction pressures.

Assessing left ventricular (LV) filling pressure (LVFP) is challenging in patients with coronary artery disease (CAD) and preserved LV ejection fraction (LVEF). We aimed to correlate left atrial strain (LAS) with two invasive complementary parameters of LVFP and compared its accuracy to other echocardiographic data to predict high LVFP. This cross-sectional, single-center study enrolled 81 outpatients with LVEF > 50% and significant CAD from a database. Near-simultaneous echocardiography and invasive measurements of both LV end-diastolic pressure (LVEDP) and LV pre-atrial contraction (pre-A) pressure were performed in each patient, based on the definition of LVEDP > 16 mmHg and LV pre-A > 12 mmHg as high LVFP. A moderate to strong correlation was observed between LAS reservoir (LASr), contractile strain, and LVEDP (r: 0.67 and 0.62, respectively; p < 0.001); the same was true for LV pre-A (r: 0.65 and 0.63, respectively; p < 0.001). LASr displayed good diagnostic performance to identify elevated LVFP, which was higher when compared to traditional parameters. Median value of LASr was higher for an isolated increase of LVEDP than for simultaneously high LV pre-A. The cutoff found to predict high LVFP was lower for LV pre-A than that one for LVEDP. In the current study, LASr did not provide an additional contribution to the 2016 diastolic function algorithm. LAS is a valuable tool for predicting LVFP in patients with CAD and preserved LVEF. The choice of LVEDP or LV pre-A as the representative marker of LVFP leads to different cutoffs to predict high pressures. The best strategy for adding this tool to a multiparametric algorithm requires further investigation.

Effect of sevoflurane on serum CK-MB levels after percutaneous coronary stent placement: A prospective randomized clinical trial.

OBJECTIVES: Markers of myocardial injury, such as creatine kinase-myocardial band (CK-MB) mass, are elevated in up to 30% of patients undergoing percutaneous coronary intervention (PCI) with stent deployment. This elevation represents myocardial injury that can impact the patient in the long term, including the risk of death. Sevoflurane, an inhaled anesthetic, may have cardioprotective properties that benefit patients undergoing PCI. The primary objective was to compare serum CK-MB mass raise in patients who received sevoflurane to those who received a placebo prior to PCI. METHODS: We enrolled patients with coronary artery disease who were eligible for PCI in a randomized (1:1), double-blind, placebo-controlled trial; patients having experienced acute myocardial infarction within 72 hours and those with saphenous vein graft stenting were excluded. Patients (n = 1254) were randomized to receive sevoflurane (2% inspired fraction) or placebo (oxygen alone) for 30 minutes prior to PCI. Additionally, we compared substantial elevations in CK-MB mass (defined as >5x the upper limit of normal), length of stay in the intensive care unit and in-hospital, and 1-year mortality. RESULTS: Sevoflurane was unable to promote cardioprotection, as determined by CK-MB mass levels (sevoflurane group: 2.52 ± 9.64; control group: 1.84 ± 8.58; P=.32). No effect was noticed on the reduction among patients who (AQ: with?) increase (AQ: increased?) marker levels (prevalence of increase in CK-MB mass greater than the upper limit of normality was 30.8% in the sevoflurane group and 28.9% in the control group; P=.33; 4.6% vs 3.1%, respectively, for increases 5x above the upper limit of normality [P=.21]). CONCLUSIONS: Sevoflurane failed to reduce myocardial injury after PCI. Therefore, its usage should not be routinely recommended.

Independent Clinical and Echocardiographic Predictors of Restenosis After Percutaneous Mitral Balloon Commissurotomy in a Large, Consecutive Cohort Followed for 24 Years.

OBJECTIVE: To enlighten preprocedural risk factors of mitral valve restenosis in a large, single-center cohort of patients submitted to percutaneous mitral balloon commissurotomy (PMBC) for the treatment of mitral stenosis (MS) secondary to rheumatic heart disease. METHODS: This is a database analysis of a single-center, high-volume tertiary institution involving all consecutive PMBC procedures performed in the mitral valve (MV). Restenosis was diagnosed when MV area was <1.5 cm² and/or loss of 50% or more of the immediate procedural result aligned with the return/worsened symptoms of heart failure. The primary endpoint was to determine the preprocedural independent predictors of restenosis after PMBC. RESULTS: Among a total of 1921 PMBC procedures, 1794 consecutive patients without previous intervention were treated between 1987 and 2010. Throughout 24 years of follow-up, MV restenosis was observed in 483 cases (26%). Mean age was 36 years and most (87%) were female. Median follow-up duration was 9.03 years (interquartile range, 0.33-23.38). Restenosis population, however, presented a significantly lower age at the procedure time as well as a higher Wilkins-Block score. At multivariate analysis, independent preprocedure predictors of restenosis were left atrium diameter (hazard risk [HR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.04), preprocedure maximum gradient (HR, 1.02; 95% CI, 1.00-1.03; P=.04), and higher Wilkins-Block score (>8) (HR, 1.38; 95% CI, 1.14-1.67; P<.01). CONCLUSIONS: At long-term follow-up, MV restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum MV gradient, and Wilkins-Block score were found to be the only independent predictors.

Ioxaglate Versus IoDixanol for the Prevention of Contrast-Induced Nephropathy: The IDPC Trial.

BACKGROUND: Despite the potential benefits of percutaneous procedures for the assessment and treatment of coronary artery disease, these interventions require the use of iodine contrast, which might lead to contrast-induced nephropathy (CIN) and increased risk of dialysis and major adverse cardiac events (MACE). AIMS: We sought to compare two different iodine contrasts (low vs. iso-osmolar) for the prevention of CIN among high-risk patients. METHODS: This is a single-center, randomized (1:1) trial comparing consecutive patients at high risk for CIN referred to percutaneous coronary diagnostic and/or therapeutic procedures with low (ioxaglate) vs. iso-osmolarity (iodixanol) iodine contrast. High risk was defined by the presence of at least one of the following conditions: age >70 years, diabetes mellitus, non-dialytic chronic kidney disease, chronic heart failure, cardiogenic shock, and acute coronary syndrome (ACS). The primary endpoint was the occurrence of CIN, defined as a >25% relative increase and/or >0.5 mg/dL absolute increase in creatinine (Cr) levels compared with baseline between the 2nd and 5th day after contrast media administration. RESULTS: A total of 2,268 patients were enrolled. Mean age was 67 years. Diabetes mellitus (53%), non-dialytic chronic kidney disease (31%), and ACS (39%) were highly prevalent. The mean volume of contrast media was 89 ml ± 48.6. CIN occurred in 15% of all patients, with no significant difference regarding the type of contrast used (iso = 15.2% vs. low = 15.1%, P>.99). Differences were not observed in specific subgroups such as diabetics, elderly, and ACS patients. At 30-day follow-up, 13 patients in the iso-osmolarity group and 11 in low-osmolarity group required dialysis (P =.8). There were 37 (3.3%) deaths in the iso-osmolarity cohort vs. 29 (2.6%) in the low-osmolarity group (P =.4). CONCLUSION: Among patients at high risk for CIN, the incidence of this complication was 15%, and independent of the use of low- or iso-osmolar contrast.

Evaluation of the start-up of hydraulic conditions of a fluidised bed system.

The development of this research was based on the analysis of an anaerobic fluidised bed reactor from the assembly of its components to the sealing of the system and further fluidisation. A hydrometer and a Venturi were used to identify the best means of measuring the flow rate. Results produced by both devices were similar, however, the latter was less effective due to the low flow rates necessary to operate the system. The hydrometer was the most adequate device for flow rate measurements in the range between 0.1 and 1.0 m³/h, whereas the Venturi proved to be an adequate device for the flow in the range between 0.3 and 0.7 m³/h. Sand with grain sizes varying from 357 to 1000 µm was used as support material. It was not observed statistically significant differences between the minimum fluidisation velocities related to the amount of supported material of 20% and 40% (VSM/Vusable) added to the reactor. Forty percent of the usable volume occupied with sand is adequate to reach fluidisation, instead of only the expansion of the bed. The fluidisation velocities for the sand grain size of 357 µm were 8.4 m/h ± 0.25 for 20%, and 8.6 m/h ± 0.30 for 40%, whereas for the 505 µm they were, respectively for 20% and 40%, 9.2 m/h ±0.70 and 10.1 m/h ± 0.37. The hydraulic tests allow to stress that sand grain sizes varying from 357 to 505 µm are recommended to be used in a system with similar characteristics.

Optical Coherence Tomography Versus Intravascular Ultrasound and Angiography to Guide Percutaneous Coronary Interventions: The iSIGHT Randomized Trial.

[Figure: see text].

Novel Prognostic Score for Immediate and Late Success After Percutaneous Mitral Balloon Commissurotomy in Patients With Mitral Stenosis.

OBJECTIVES: Percutaneous mitral balloon commissurotomy (PMBC) remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis (MS) and suitable anatomy. The objective of this study was to propose a new score for the prediction of immediate and late success. METHODS: This is a single-center, retrospective analysis of all 1582 patients with severe mitral stenosis who underwent PMBC from August 1987 to July 2010. The composite outcome was cardiovascular death, new PMBC, or mitral valve repair surgery up to 24 years of follow-up. RESULTS: Mean patient age was 36.8 ± 12.9 years, most (86.4%) were female, and Wilkins score was between 9-11 in 49.1% of patients. In the multivariate analysis, the predictors of immediate success were age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99; P=.01), left atrium size (OR, 0.96; 95% CI, 0.93-0.99; P=.01), mean preprocedure mitral gradient (OR, 0.93; 95% CI, 0.89-0.96; P<.001), intermediate Wilkins score 9-11 (OR, 0.62; 95% CI, 0.40-0.94; P=.02), and high Wilkins score ≥12 (OR, 0.35; 95% CI, 0.16-0.76; P<.01). For prediction of late events, age (hazard ratio [HR], 0.98; 95% CI, 0.97-0.98; P<.001), New York Heart Association class III-IV (HR, 1.50; 95% CI, 1.18-1.92; P<.001), left atrium size (HR, 1.02; 95% CI, 1.02-0.04; P<.01), and high Wilkins score ≥12 (HR, 2.02; 95% CI, 1.30-3.15; P<.01) were significant. Two nomograms were developed using significant predictors from the model. CONCLUSIONS: In this large population, not only the Wilkins score, but also clinical and hemodynamic features, seem to be relevant in predicting immediate and late success for patients with rheumatic MS who underwent PMBC.

Avaliação funcional, anatômica e ultrassonográfica no tratamento de lesão arterial coronariana complexa / Functional, anatomical and ultrasonographic assessment in the treatment of complex coronary artery lesion

Apresentação clínica ID: A. A. G., 47 a, sexo feminino AP: HAS, DLP, sem história de eventos CV prévios HDA: Paciente com angina CCS II de início há 1 ano. ECG: RS, eixo preservado, sem alterações segmento ST ECO TT (30/09/2022): FE 49% Hipocinesia difusa discreta. Avaliação angiográfica Lesão importante do óstio ao terço proximal de ADA. Sem outras lesões importantes. Tomada de decisão optado por realizar avaliação fisiológica invasiva para determinar gravidade de lesão Método não-hiperêmico (RFR): resultado positivo para isquemia ­ 0,86. Intervenção Tratamento percutâneo de lesão guiado por IVUS ALM: 3.11 mm² ao nível do óstio de ADA. Diâmetro de referência distal ­ 3.44 mm. Extensão 26 mm. Evolução pós-intervenção: IVUS controle: Adequada expansão, aposição e cobertura, sem sinais de complicações. Paciente mantém-se estável e assintomática desde então. Conclusão Importante complementar avaliação da gravidade da lesão angiográfica, principalmente em região anatomicamente complexa para intervenção. Utilização de imagem intracoronária auxilia na otimização do tratamento, na escolha correta do tamanho e diâmetro de balões e stents, bem como no controle pós intervenção.

Effect of sevoflurane on serum CK-MB levels after percutaneous coronary stent placement: A prospective randomized clinical trial

OBJECTIVES. Markers of myocardial injury, such as creatine kinase-myocardial band (CK-MB) mass, are elevated in up to 30% of patients undergoing percutaneous coronary intervention (PCI) with stent deployment. This elevation represents myocardial injury that can impact the patient in the long term, including the risk of death. Sevoflurane, an inhaled anesthetic, may have cardioprotective properties that benefit patients undergoing PCI. The primary objective was to compare serum CK-MB mass raise in patients who received sevoflurane to those who received a placebo prior to PCI. METHODS. We enrolled patients with coronary artery disease who were eligible for PCI in a randomized (1:1), double-blind, placebo-controlled trial; patients having experienced acute myocardial infarction within 72 hours and those with saphenous vein graft stenting were excluded. Patients (n = 1254) were randomized to receive sevoflurane (2% inspired fraction) or placebo (oxygen alone) for 30 minutes prior to PCI. Additionally, we compared substantial elevations in CK-MB mass (defined as >5x the upper limit of normal), length of stay in the intensive care unit and in-hospital, and 1-year mortality. RESULTS. Sevoflurane was unable to promote cardioprotection, as determined by CK-MB mass levels (sevoflurane group: 2.52 ± 9.64; control group: 1.84 ± 8.58; P=.32). No effect was noticed on the reduction among patients who (AQ: with?) increase (AQ: increased?) marker levels (prevalence of increase in CK-MB mass greater than the upper limit of normality was 30.8% in the sevoflurane group and 28.9% in the control group; P=.33; 4.6% vs 3.1%, respectively, for increases 5x above the upper limit of normality [P=.21]). CONCLUSIONS. Sevoflurane failed to reduce myocardial injury after PCI. Therefore, its usage should not be routinely recommended.

Perfil de pacientes submetidos à exame de cateterismo cardíaco e cineangiocoronariografia em um centro de referência terciário de grande volume: análise de 59.239 casos / Profile of patients undergoing cardiac catheterization and coronary angiography in a large-volume tertiary referral center: analysis of 59,239 cases

FUNDAMENTOS: O estudo angiográfico invasivo permanece como o exame diagnóstico padrão-ouro para a determinação e quantificação da gravidade e extensão da doença arterial coronária (DAC) obstrutiva. No geral, a maioria das indicações para realização do exame na atualidade, inclui procedimentos eletivos em pacientes com suspeita de DAC obstrutiva significativa e pacientes com quadro clínico agudo ou recente de síndrome coronária aguda (SCA). OBJETIVO: Determinar o perfil clínico, dados de procedimentos e achados angiográficos em termos de gravidade e extensão da DAC em pacientes submetidos à exame diagnóstico de cateterismo cardíaco esquerdo e cineangiocoronariografia em centro de referência terciário de grande porte e volume em sua prática diária. Métodos: Entre 2007 e 2023, foram realizados cerca de 59.239 exames diagnósticos de cateterismo cardíaco esquerdo mais cineangiocoronariografia na rotina da prática diária em um centro de referência terciário de grande volume. Os dados demográficos basais, perfil de risco, apresentação clínica e achados angiográficos foram obtidos a partir do banco de dados dedicado do Serviço de Cardiologia Invasiva da instituição, cujo preenchimento é atrelado a elaboração e liberação do laudo do exame. RESULTADOS: A média das idades era 69,01±11,34 anos e 61,29% eram do sexo masculino. Em relação aos fatores de risco para DAC, 32,48% tinham diabetes (5,1% insulino dependente), 78,1% hipertensão arterial sistêmica, 58,45% dislipidemia, 24,05% infarto agudo do miocárdio prévio, 10,74% intervenção coronária percutânea prévia, 2,01% acidente vascular encefálico prévio, 2,58% doença vascular periférica (diagnosticada previamente), 2,42% com insuficiência cardíaca descompensada e 19,95% insuficiência renal crônica. Tabagismo atual e histórico foram encontrados em 13,78% e 22,7%, respectivamente. O diagnóstico prévio de doença valvar associada foi encontrado em 6,10% e a média do índice de massa corpórea era de 27,72±6,05 kg/m2. No geral, a apresentação clínica de SCA (fase aguda ou recente) foi encontrada em um 40% dos casos. Em termos de procedimento, a via de acesso radial foi utilizada em cerca de um terço dos casos, introdutores 5-Fr. e 6-Fr foram utilizados em 23,65 e 75,96%, respectivamente, e a média de volume total de contraste foi de 63,71±29,19 mL. Sobre os achados angiográficos, o padrão de dominância foi direita em 79,84%, esquerda em 8,45% e co-dominância em 10,72%. A ventriculografia esquerda foi realizada em 95,67% dos casos e observou-se algum grau de disfunção em 41,72%. Cerca de 60,85% dos casos evidenciaram a presença de DAC obstrutiva significativa (>50%), sendo 23,97% de padrão uniarterial, 17,87% biarteriais, 16,80% triarteriais e 1,66% incidindo no Tronco da coronária esquerda. CONCLUSÕES: Nesta análise, observa-se um elevado perfil de risco do ponto de vista cardiovascular, incluindo múltiplas comorbidades, predomínio de pacientes de maior faixa etária e gênero masculino, apresentação clínica aguda se fez presente em dois quintos dos casos realizados. Ademais, a maioria dos pacientes apresentou DAC significativa que está associada a pior prognóstico, devendo existir uma busca constante na otimização e cumprimento de metas terapêuticas.

Left atrial strain as a predictor of left ventricular filling pressures in coronary artery disease with preserved ejection fraction: a comprehensive study with left ventricular end-diastolic and pre-atrial contraction pressures

Assessing left ventricular (LV) filling pressure (LVFP) is challenging in patients with coronary artery disease (CAD) and preserved LV ejection fraction (LVEF). We aimed to correlate left atrial strain (LAS) with two invasive complementary parameters of LVFP and compared its accuracy to other echocardiographic data to predict high LVFP. This cross-sectional, single-center study enrolled 81 outpatients with LVEF > 50% and significant CAD from a database. Near-simultaneous echocardiography and invasive measurements of both LV end-diastolic pressure (LVEDP) and LV pre-atrial contraction (pre-A) pressure were performed in each patient, based on the definition of LVEDP > 16 mmHg and LV pre-A > 12 mmHg as high LVFP. A moderate to strong correlation was observed between LAS reservoir (LASr), contractile strain, and LVEDP (r: 0.67 and 0.62, respectively; p < 0.001); the same was true for LV pre-A (r: 0.65 and 0.63, respectively; p < 0.001). LASr displayed good diagnostic performance to identify elevated LVFP, which was higher when compared to traditional parameters. Median value of LASr was higher for an isolated increase of LVEDP than for simultaneously high LV pre-A. The cutoff found to predict high LVFP was lower for LV pre-A than that one for LVEDP. In the current study, LASr did not provide an additional contribution to the 2016 diastolic function algorithm. LAS is a valuable tool for predicting LVFP in patients with CAD and preserved LVEF. The choice of LVEDP or LV pre-A as the representative marker of LVFP leads to different cutoffs to predict high pressures. The best strategy for adding this tool to a multiparametric algorithm requires further investigation.

Routine ultrasound-guided femoral access and use of one vascular closure device for femoral hemostasis after TAVR: feasibility and safety

INTRODUCTION: The transfemoral TAVR is a safe and effective treatment for severe and symptomatic aortic stenosis, regardless of the surgical risk profile. The vascular access and hemostasis are fundamental steps of the procedure and have impact on the prognosis. Traditionally, the arterial hemostasis has been obtained through the use of 2 or more vascular closure devices (ProGlide, Perclose) or the association of vascular closure devices (suture + collagen). Nevertheless, the reduction of sheet size and routinary use of ultrasound guided puncture, the use of one vascular closure device could be effective in obtaining hemostasis in such patients. METHODS: Observational, prospective study, including patients submitted to transfemoral TAVR through March/2020 to April/2022. The arterial access was obtained with ultrasound assistance on all cases. From September/2021 we initiated the institutional protocol with the use of one Perclose after obtaining the femoral access (pre-closure technique). We evaluated the need for additional vascular closure devices, the presence of femoral stenosis of > 50% (according to femoral angiography at the end of the procedure) and the occurrence of bleeding (according to the VARC-III criteria). RESULTS: In the period, a total of 75 patients were submitted to transfemoral TAVR on our institution. We used 1 Perclose in 31 patients (Group A) and 2 Perclose devices on 44 patients (Group B). The characteristics of the patients at baseline; mean age of 77 7.32 years, 39% were female, and mean STS score of 3.6%. There were no significant differences between Group A and B. Balloon expandable TAVR was used in 97.3% of the patients, and in 96% of the patients the introducer sheet used was 14F. At the post-procedure femoral angiography, residual stenosis was present in only 1 (4.1%) patient on Group A and on 9 (25%) patients on Group B (p=0.034). there was no difference in major or minor bleeding with manual prolonged compression in both groups. two patients in Group A required additional vascular closure devices and no in group B. CONCLUSION: On this initial series, the ultrasound guided femoral access and the use of one vascular closure device, proved to be feasible and effective on vascular hemostasis, while reducing residual stenosis of the femoral artery when compared to the use of two vascular closure devices.

Resultados de um ano com nova prótese balão-expansível para o tratamento percutâneo da estenose valvar aórtica / One-year results with a new balloon-expandable prosthesis for the percutaneous treatment of aortic valve stenosis

A TAVI surgiu como um tratamento revolucionário para pacientes com estenose aórtica (EA) grave e sintomática, independentemente do perfil de risco cirúrgico. Novas próteses transcateter com mais baixo perfil, fácil implante e expectativa de maior durabilidade estão sendo desenvolvidas para atingir também população mais jovem e de baixo risco. Myval (Meril) é uma prótese transcateter balão-expansível de 14Fr com design para minimizar a ocorrência de leak paravalvar (LPV), e foi recentemente aprovada para uso clínico em nosso país. Relataremos a experiência inicial com este novo dispositivo. MÉTODOS: Registro prospectivo, unicêntrico, envolvendo todos os pacientes (pts) consecutivos submetidos à TAVI com a prótese MyVal na instituição. Os resultados clínicos e ecocardiográficos foram definidos de acordo com os critérios VARC-III. RESULTADOS: Entre dez/20 e jan/23, 91 pts foram submetidos a TAVI. A média de idade foi de ¬¬¬¬75 ± 6,9 anos, sendo ¬¬¬40% do sexo feminino; o escore STS foi de 3,43 ± 1,64%. O gradiente médio (GM) e a área valvar aórtica pré-procedimento foram de 56,4 ± 17,6 mmHg e 0,7 ± 0,2 cm2, respectivamente. Todos os procedimentos foram realizados sob abordagem minimalista com acesso femoral percutâneo, exceto 1 caso realizado por via carotídea. 11 pts apresentavam EA bicúspide, 7% possuíam disfunção ventricular grave (< 30%) e sete foram submetidos a um procedimento valve-in-valve aórtico. Sucesso do procedimento ocorreu em todos os casos, e o ecocardiograma pós-TAVI revelou GM médio de 4,9 mmHg, com LPV > leve em apenas dois casos (2,1%). Marcapasso definitivo foi necessário em 3 pts (3,3%), e o tempo médio de internação foi de 2,8 dias. Aos 30 dias, ocorreram dois óbitos: um por COVID-19 (em paciente que apresentou sangramento maior e internação prolongada), outro por causa cardiovascular, alem de 2 óbitos no seguimento de seis meses devido a causa não cardíaca. Aos 12 meses de seguimento, 100% dos pacientes apresentam-se em classe NYHA I ou II, o GM e a área valvar foram respetivamente de 11,75 ± 7,93 mmHg e 1,62 ± 0,08 cm2. CONCLUSÃO: Em nossa experiência, o emprego da prótese balão-expansível Myval resultou em desfechos clínicos e ecocardiográficos satisfatórios, estando associada à baixa taxa de complicações do procedimento no seguimento de 1 ano.

Ioxaglate versus IoDixanol for the prevention of contrast-induced nephropathy: the IDPC trial

BACKGROUND. Despite the potential benefits of percutaneous procedures for the assessment and treatment of coronary artery disease, these interventions require the use of iodine contrast, which might lead to contrast-induced nephropathy (CIN) and increased risk of dialysis and major adverse cardiac events (MACE). Aims. We sought to compare two different iodine contrasts (low vs. iso-osmolar) for the prevention of CIN among high-risk patients. METHODS. This is a single-center, randomized (1:1) trial comparing consecutive patients at high risk for CIN referred to percutaneous coronary diagnostic and/or therapeutic procedures with low (ioxaglate) vs iso-osmolarity (iodixanol) iodine contrast. High risk was defined by the presence of at least one of the following conditions: age >70 years, diabetes mellitus, non-dialytic chronic kidney disease, chronic heart failure, cardiogenic shock, and acute coronary syndrome (ACS). The primary endpoint was the occurrence of CIN, defined as a >25% relative increase and/or >0.5 mg/dL absolute increase in creatinine (Cr) levels compared with baseline between the 2nd and 5th day after contrast media administration. RESULTS. A total of 2268 patients were enrolled. Mean age was 67 years. Diabetes mellitus (53%), non-dialytic chronic kidney disease (31%), and ACS (39%) were highly prevalent. The mean volume of contrast media was 89 ml ± 48.6. CIN occurred in 15% of all patients, with no significant difference regarding the type of contrast used (iso = 15.2% vs low = 15.1%, P>.99). Differences were not observed in specific subgroups such as diabetics, elderly, and ACS patients. At 30-day follow-up, 13 patients in the iso-osmolarity group and 11 in low-osmolarity group required dialysis (P=.8). There were 37 (3.3%) deaths in the iso-osmolarity cohort vs 29 (2.6%) in the low-osmolarity group (P=.4). CONCLUSION. Among patients at high risk for CIN, the incidence of this complication was 15%, and independent of the use of low- or iso-osmolar contrast.

Impacto da seleção para participar de um estudo randomizado no perfil clínico/angiográfico e nos resultados: hospitalares de pacientes diabéticos submetidos à intervenção coronária percutânea / Impact of selection to participate in a randomized study on the clinical/angiographic profile and results: hospital admissions of diabetic patients undergoing percutaneous coronary intervention

INTRODUÇÃO: Em geral, pacientes (p) incluídos em estudos randomizados são selecionados e exibem perfil clínico/angiográfico de menor gravidade do que os do mundo real. Na última década, ensaios clínicos envolvendo intervenções coronárias percutâneas (ICP) com novos modelos de stents farmacológicos (SF) tem primado por estabelecer apenas critérios clínicos de avaliação dos resultados, evitando a necessidade de reestudo angiográfico compulsório na evolução, o que pode atenuar discrepâncias significativas entre casos selecionados ou não para participar dos estudos, assim como permitir a inclusão de mais p. OBJETIVO: O objetivo desta investigação foi avaliar a hipótese supracitada. MÉTODOS: Recentemente foi realizada em nosso Serviço a inclusão de p diabéticos (PD) de forma prospectiva e randomizada num estudo que avaliou um novo modelo de SF, quando comparado a outro modelo utilizado na rotina. Havia critérios de exclusão restritos. Decidimos comparar os perfis clínico e angiográfico de PD incluídos ou não no estudo, finalizando aleatoriamente a amostra quando fosse incluído o centésimo p. Desta forma, entre 10/2020 e 07/2021, foram realizadas 336 ICP em PD de forma prospectiva, subdivididos em 2 grupos: A) 100(29%) PD incluídos no estudo; B) os 236(71%) restantes. Estabeleceram-se como significativos valores de p<0.05. RESULTADOS: Sexo, idade, diabetes dependente de insulina e extensão da doença coronária não diferiram entre os grupos. Predominaram significativamente no grupo B: disfunção renal crônica(21% vs 7%; p=0.0033), idade superior a 70 anos(37% vs 23% p=0.015), antecedente de ICP(32% vs 13%; p=<0.001), ICP para pontes de veia safena(5% vs 0% p=0.03) e infarto com elevação de ST(19% vs 8%; p=0.017); antecedente de cirurgia de revascularização miocárdica previa(10% vs 4% P=0.08) e ICP uniarterial (69% vs 57% p=0.054) também foram mais observados em B, mas não de forma significante. Predominaram no grupo A: ICP de múltiplos vasos (43% vs 25%; p=0.0016), apresentação clínica de angina estável (47% vs 31%; p=0.009) e revascularização completa (62% vs 47%; p=0.0016). Embora a permanência de UTI do grupo B foi maior (1.1(±3.5) vs 0.27(±1.5) P=0.024) os resultados imediatos da fase hospitalar, em conjunto ou individualmente, não diferiram. CONCLUSÕES: 1) Cerca de um em cada três PD tratados foram incluídos no estudo; 2) mesmo com critérios de inclusão/exclusão menos rígidos, observamos perfil clínico/angiográfico de menor complexidade nos casos incluídos.