Avaliação de setup para teste de elevação de pós-carga em pacientes com insuficiência cardíaca com fração de ejeção preservada: um estudo experimental / Evaluation of afterload elevation test setup in heart failure patients with preserved ejection fraction: an experimental study

INTRODUÇÃO: A Insuficiência Cardíaca com Fração de Ejeção Preservada (ICFEP) é uma doença de alta prevalência e de difícil diagnóstico devido ao fato que parte dos pacientes apresenta alterações apenas quando submetidos a determinadas condições de estresse hemodinâmico como elevação da pré-carga e da pós-carga do ventrículo esquerdo. OBJETIVOS: Avaliar a efetividade de um setup para elevação da pós-carga em pacientes com ICFEP. MÉTODOS: Realizou-se medida da pressão arterial sistólica (PAS), pressão arterial diastólica (PAD) e frequência cardíaca (FC) em repouso no membro superior direito com o paciente em decúbito supino seguindo as diretrizes da Sociedade Brasileira de Cardiologia. Em seguida, realizou-se um teste de elevação de pós-carga através da contração isométrica da mão esquerda com 60% da força máxima com um dinamômetro combinada com compressão pneumática de ambos os membros inferiores 20 mmHg acima da pressão sistólica utilizando dois esfigmomanômetros. Uma nova medida da pressão e frequência cardíaca foi realizada após 30s de início da manobra. Para comparação das métricas entre repouso e estresse, utilizou-se o teste-t pareado com intervalo de confiança de 95%. RESULTADOS: A população do estudo foi de 37 pacientes: 17 controles e 20 com ICFEP. A idade foi 58 ± 15 anos e 19 (51%) eram do sexo feminino. Houve diferença significativa para PAS: 128,2 ± 17,7 mmHg e 146,7 ± 19,9 mmHg (p<0,001) e FC 66 ± 11 bpm x 77 ± 14 bpm (p<0,001) repouso e estresse, respectivamente (Figura 1). CONCLUSÃO: O setup utilizado foi efetivo em elevar a pós-carga na população estudada. Os dados desta pesquisa têm grande potencial de aplicação para protocolos alternativos ao exercício padrão em cicloergômetro como teste provocativo para diagnóstico de ICFEP. Palavras-chaves: Insuficiência cardíaca com fração de ejeção preservada, Aumento de pós-carga, Teste de Estresse.

Ferramenta para processamento e armazenamento de curvas de strain para estudo da mecânica miocárdica / Tool for processing and storing strain curves for studying myocardial mechanics

INTRODUÇÃO: As curvas de deformação cardíacas derivadas de Speckle Tracking, permitem avaliação detalhada de diversos aspectos da mecânica miocárdica, entretanto o estudo de novos parâmetros é limitado por restrições impostas pelos softwares proprietários dos diferentes fabricantes. OBJETIVO: Desenvolver um programa com interface gráfica que permita visualizar e processar as curvas de Strain e Strain Rate facilitando o desenvolvimento de pesquisas. MÉTODOS: Inicia-se com a exportação das curvas de Strain do programa do fabricante. Elas são a entrada do software que as converte em variáveis do Matlab. Pode-se então, selecionar o exame de interesse, ou seja, paciente e janela de aquisição. As curvas de Strain e Strain Rate são exibidas e é possível selecionar os segmentos de interesse e, caso exista, outros exames do mesmo paciente com a mesma janela de aquisição. As curvas de deformação são exibidas sincronizadas com o Eletrocardiograma possibilitando ter em uma única tela o sinal elétrico e o sinal de deformação. Além disso, também é possível anotar o tempo de abertura e fechamento das válvulas com relação ao pico do QRS, que é encontrado automaticamente e pode ser editado caso necessário. As demais abas do programa apresentam as seguintes funcionalidades: em "Curvas Separadas" é possível visualizar as porções das curvas correspondentes à fase do ciclo cardíaco desejada, na aba "Plot Simul" é possível visualizar, simultaneamente, uma janela do ventrículo esquerdo e uma de átrio esquerdo sincronizados pelos respectivos ECGs, e na aba "Doppler" é possível verificar a imagem de um doppler e utilizá-lo para demarcar os tempos de válvula. RESULTADOS: O software funcional foi implementado em um ambulatório, sendo responsável por converter e processar curvas de mais de 2000 arquivos exportados, segmentando-os nas fases específicas do ciclo cardíaco (relaxamento e contração isovolumétricos, períodos de ejeção, enchimento rápido e enchimento lento) de exames utilizados para desenvolvimento de uma linha de pesquisa. CONCLUSÕES: O software livre desenvolvido no IDPC permite explorar as curvas de deformação cardíaca de maneira personalizada sendo adequado ao estudo do ecocardiograma em diversas situações.

Ferramentas para otimização de digitalização, armazenamento e visualização de dados do teste cardiopulmonar de exercício / Tools for optimizing the digitization, storage and visualization of cardiopulmonary exercise test data

INTRODUÇÃO: O teste cardiopulmonar de exercício (TCPE) é o padrão ouro para função cardiorrespiratória de pacientes. Por conta disso, os dados obtidos por meio deste são extremamente relevantes em pesquisas clínicas. No entanto, há situações em que, por conta de limitações dos equipamentos, a obtenção e armazenamento dos resultados destes exames se torna um processo complicado e dispendioso. OBJETIVO: Desenvolver ferramentas capazes de: 1) Digitalizar os dados nos formatos disponibilizados pelos equipamentos e montar um banco de dados; 2) Permitam uma análise, visualização e comparação otimizadas desses dados. MÉTODOS: Inicialmente, os laudos obtidos diretamente do equipamento são lidos por um programa, os valores dos parâmetros são armazenados durante os tempos mais relevantes do teste (limiares aeróbico e anaeróbico, VO2 máximo etc.) em um arquivo que servirá como banco de dados relacional. Esta base de dados é então utilizada para montar um Dashboard onde se pode selecionar a variável e o intervalo de tempo que se deseja comparar entre os grupos. Nele são mostrados histogramas e gráficos violinos para se comparar visualmente os grupos (figuras 1 e 2) e estatísticas dos dados coletados junto a: 1) Resultado de um teste de normalidade para o parâmetro escolhido; 2) Resultado (p-valor) de um teste de hipótese (paramétrico caso a distribuição seja considerada normal, ou não paramétrico caso contrário); 3) Os tamanhos mínimos que as amostras devem possuir para que os resultados dos testes possam ser considerados estatisticamente significativos. Por fim, é possível analisar, em uma segunda página desta ferramenta os valores individuais de cada paciente, sendo possível filtrar e visualizar apenas os valores dentro de um intervalo desejado. (Figura 4) RESULTADOS: As ferramentas desenvolvidas foram utilizadas na base de dados dos pacientes do Ambulatório de Medicina Cardiovascular Personalizada com os resultados de 102 exames. O Dashboard foi utilizado para realizar um estudo comparativo entre os pacientes homens e mulheres do ambulatório com resultados coerentes com a literatura. CONCLUSÕES: Com estas ferramentas foi possível, rapidamente, digitalizar e armazenar os dados montando um arquivo com as informações de todos pacientes. Ademais, também permitiu realizar um estudo exemplo comparando todos pacientes gerando imagens que auxiliam a visualizar os resultados e os respectivos p-valores para cada comparação.

Ocorrência de distúrbios de condução e implante de marca-passo definitivo em pacientes submetidos a TAVI com abordagem minimalista / Occurrence of conduction disorders and permanent pacemaker implantation in patients undergoing TAVI with a minimalist approach

INTRODUÇÃO: O surgimento de distúrbios de condução e a necessidade de implante de marca-passo (MP) definitivo estão entre as complicações mais comuns relacionadas ao TAVI. Na aplicação do TAVI minimalista - em que se objetiva alta hospitalar oportuna < 48 horas - tais complicações são de central importância, e sua ocorrência deve ser monitorada sistematicamente. OBJETIVO: Avaliar a prevalência de alterações eletrocardiográficas sabidamente preditoras de distúrbios de condução após TAVI e a incidência de MP definitivo em até 30 dias após o procedimento, em pacientes (pctes) não-selecionados submetidos a TAVI minimalista em um hospital terciário do SUS. MÉTODOS: Estudo observacional e prospectivo, com inclusão de pctes consecutivos submetidos a TAVI minimalista no período de Set/2020 a Jan/2022, com análise do ECG antes e após a TAVI conforme protocolo institucional. Verificado a presença de alterações de ritmo e bloqueios atrioventriculares (BAV) e intraventriculares e a indicação de MP definitivo durante a internação e um mês após a alta hospitalar. RESULTADOS: Foram avaliados 50 pctes, com média de idade de 79,2 anos, com STS médio de 2,64% e 20 (40%) mulheres. Próteses balão-expansíveis foram utilizadas mais frequentemente (76%). O ritmo e distúrbios de condução antes da TAVI encontrados foram: • Ritmo sinusal: 41 (82%) • Fibrilação atrial: 12 (24%) • BAV 1 grau: 14 (28%) • Bloqueio de ramo direito: 3 (6%) • Bloqueio de ramo esquerdo: 7 (14%) • Ritmo de MP: 4 (8%) A ocorrência de bradiarritmias que justificassem monitorização estendida e vigilância intra-hospitalar por ao menos 24 horas ocorreu em 7 (14%) pcts, sendo: • Bloqueio atrioventricular total: 1 (2,5%) • Bloqueio atrioventricular avançado: 1 (2,5%) • Fibrilação atrial de baixa resposta ventricular: 2 (5%) • Ritmo juncional: 2 (5%) • Bradicardia sinusal e distúrbio de condução intraventricular: 1 (2,5%) Houve indicação de MP definitivo para 1 (2,5%) pcte. Não houve reinternação devido a distúrbios de condução ou implante de MP até 30 dias após a TAVI. CONCLUSÃO: Em nossa experiência, poucos pctes submetidos a TAVI com estratégia minimalista apresentaram distúrbios de condução necessitaram postergar a alta hospitalar. Apenas um paciente requereu implante de MP definitivo. A aplicação de protocolo institucional com alta hospitalar oportuna (<48h) não esteve relacionada à maior risco de distúrbios de condução em curto prazo (30 dias).

A 4-item PRECISE-DAPT score for dual antiplatelet therapy duration decision-making

The originally-proposed PRECISE-DAPT score is a 5-item risk score supporting decision-making for dual antiplatelet therapy1 duration after PCI. It is unknown if a simplified version of the score based on 4 factors (age, hemoglobin, creatinine clearance, prior bleeding), and lacking white-blood cell count, retains potential to guide DAPT duration. The 4-item PRECISE-DAPT was used to categorize 10,081 patients who were randomized to short (3-6 months) or long (12-24 months) DAPT regimen according to high (HBR defined by PRECISE-DAPT ≥25 points) or non-high bleeding risk (PRECISE-DAPT<25) status. Long treatment duration was associated with higher bleeding rates in HBR (ARD +2.22% [95% CI +0.53 to +3.90]) but not in non-HBR patients (ARD +0.25% [-0.14 to +0.64]; pint = 0.026), and associated with lower ischemic risks in non-HBR (ARD -1.44% [95% CI -2.56 to -0.31]), but not in HBR patients (ARD +1.16% [-1.91 to +4.22]; pint = 0.11). Only non-HBR patients experienced lower net clinical adverse events (NACE) with longer DAPT (pint = 0.043). A 4-item simplified version of the PRECISE-DAPT score retains the potential to categorize patients who benefit from prolonged DAPT without concomitant bleeding liability from those who do not. (AU)

Impacto da insuficiência tricúspide no prognóstico de pacientes submetidos à troca de valva aórtica transcateter ­ revisão sistemática e metanálise / Impact of tricuspid regurgitation on the prognosis of patients undergoing transcatheter aortic valve replacement - systematic review and meta-analysis

INTRODUÇÃO: A correção da estenose aórtica (EAo) por meio do implante por cateter de prótese aórtica (TAVI) tem sido cada vez mais realizada. No planejamento do procedimento, devem ser cuidadosamente avaliados fatores que influenciam o prognóstico, dentre estes, o grau de repercussão cardíaca estrutural e funcional secundário a EAo, por vezes inclusive com valvopatias concomitantes como insuficiência mitral e tricúspide (IT). A IT está presente em até 10% dos pacientes com EAo e estudos indicam mortalidade maior neste subgrupo. Entretanto, permanece incerto o verdadeiro papel da IT na evolução dos pacientes submetidos ao TAVI. O objetivo dessa revisão sistemática e metanálise é sintetizar e quantificar as evidências científicas disponíveis sobre o impacto da IT pré-procedimento na mortalidade a curto e longo-prazo de pacientes submetidos ao TAVI. MÉTODOS: De acordo com as recomendações PRISMA e MOO SE, foram pesquisados artigos originais, publicados até abril de 2019, em várias bases (MEDLINE/PubMed, SCOPUS, EMBASE, LILACS e Web of Science), que tenham reportado o grau de IT pré TAVI por meio de ecocardiograma, além da mortalidade por qualquer causa. Metanálises foram realizadas de acordo com a estratificação por tempo de follow-up, utilizando modelos de efeito fixo e random. A heterogeneidade entre os estudos foi avaliada pelo I2. RESULTADOS: Dos 301 encontrados, 16 estudos foram incluídos na revisão sistemática e 14 estudos na metanálise (> 31. 500 participantes). Pacientes com IT de grau moderado ou grave pré-TAVI apresentam mortalidade por qualquer causa significativamente maior do que aqueles com IT ausente ou de grau leve, tanto em até 30 dias (HR 1. 70; IC 95%1. 09-2. 66) quanto em seguimento longo (média de 1,4 ano) (HR 95% 1. 63; IC 1. 32-2. 03). Esse efeito foi homogêneo em ambos os subgrupos de follow-up (I2 = 42. 1% e 41. 4%, com p valores de 0,159 e 0,082, respectivamente). CONCLUSÃO: Existe evidência sugestiva de que maiores graus de IT estão associados a pior prognóstico em pacientes que serão submetidos ao TAVI. Assim, a avaliação criteriosa da valva tricúspide deve ser considerada no planejamento pré-TAVI, tanto para indicação precisa do melhor momento de correção da EAo, quanto para redefinir estratégias para o manejo de pacientes que sabidamente apresentam pior evolução. Figura 1 ­ Metanálise para mortalidade a curto-prazo (follow-up até 30 dias). Figura 2 ­ Metanálise para mortalidade a longo-prazo (follow-up médio 1,4 ano).

Use of rapamycin-impregnated stents in coronary arteries.

FIM STUDY: We investigated the 2-year safety and efficacy of sirolimus-eluting stents. Thirty patients had a single 18-mm sirolimus-eluting coronary stent implanted. Twenty-eight patients underwent angiographic and intravascular ultrasound follow-up at 2 years. No death occurred during the study period. No patient developed in-stent restenosis. One patient had a 52% in-lesion stenosis that required repeated revascularization and another patient underwent target vessel revascularization. Neointimal hyperplasia volume was minimal at 2 years in both groups. This study demonstrates the 2-year safety and efficacy of sirolimus-eluting stenting. The slow release formulation showed slight superiority over the fast-release formulation in preventing late lumen loss, which was minimal in both groups. RAVEL TRIAL: This-study was a randomized, double-blind study that included 238 patients at 19 medical centers (15 in Europe, 3 in Brazil, and 1 in Mexico). Patients were eligible for the study if they were between 18 and 85 years of age, and had been given a diagnosis of stable or unstable angina or silent ischemia. Additional eligibility criteria were presence of a single primary target lesion in a native coronary artery that was 2.5 to 3.5 mm in diameter and that could be covered by an 18-mm stent stenosis of 51% to 99% of the luminal diameter and a flow rate of grade 1 or higher according to the Thrombolysis in Myocardial Infarction. RESULTS: One hundred twenty patients were randomly assigned to receive the sirolimus-eluting stent, and 118 were assigned to receive the standard stent. At 6 months, the degree of neointimal proliferation, manifested as the mean (+/-SD) late luminal loss, was significantly lower in the sirolimus-stent group (-0.01 +/- 0.33 mm) than in the standard-stent group (0.80 +/- 0.53 mm, P <.001). None of the patients in the sirolimus-stent group, as compared with 26.6% of those in the standard-stent group, had restenosis of >/=50% of the luminal diameter (P <.001). There were no episodes of stent thrombosis. During a follow-up period of up to 1 year, the overall rate of major cardiac events was 5.8% in the sirolimus-stent group and 28.8% in the standard-stent group (P <.001). The difference was due entirely to the higher rate of revascularization of the target vessel in the standard-stent group. CONCLUSION: Patients with angina who received sirolimus-eluting stents for the treatment of single, primary lesions in native coronary arteries had no angiographic evidence of late luminal loss or in-stent restenosis at 6 months, no episodes of thrombosis, and a very low rate of cardiac events at 1 year.

[Acute occlusion after coronary angioplasty. Early management and late course]. / Oclusão aguda pós-angioplastia coronária. Manuseio precoce e evolução tardia.

PURPOSE: Assess the efficacy of the different strategies employed in the management of acute closure and verify the late prognosis of patients who develop this complication. METHODS: From january 1987, through December 1990, 2315 consecutive patients underwent percutaneous transluminal coronary angioplasty (PTCA) in our Institution. We analyzed 100 patients who had had acute closure of the dilated vessel determining the total incidence of myocardial infarction and death, the effectiveness of the different treatment strategies and clinical and angiographic predictors of poor in-hospital outcome. Late follow-up was obtained in the hospital survivors. RESULTS: The incidence of acute myocardial infarction in the group of 100 patients was 57%; death occurred in 12% of the patients. Forty-one individuals were referred to emergency bypass surgery, 35 received clinical treatment and 24 underwent redilatation of the vessel. Those managed clinically had a higher incidence of myocardial infarction compared to the ones who underwent either redilatation or surgery (74.3% versus 50% and 48.8%). The in-hospital mortality rate was significantly higher in patients with left ventricular ejection fraction < 45% (44.4%, p < 0.001) and in procedures involving the left anterior descending artery (20%, p < 0.05); patients undergoing repeat dilatation had the lower death rate (4.2% versus 8.6% in the clinical group and 17.1% in the surgical group). Late follow-up was obtained in 65 of 88 hospital survivors (mean follow-up = 17 months). Patients who underwent repeat dilatation were significantly less symptomatic in the follow-up than those who received medical therapy during the acute phase (89% versus 60.9% of patients without symptoms respectively, p < 0.05). Patients who were referred to surgery had also a tendency towards having less symptoms (87.5% of asymptomatic patients in the late follow-up) although the difference was not statistically significant (0.01 > p > 0.05). CONCLUSION: Acute coronary occlusion is a serious complication of angioplasty and is associated with high rates of major complications (myocardial infarction, death). Low left ventricular ejection fraction and PTCA involving the left anterior descending are predictors of higher in-hospital mortality in patients with acute closure. Late outcome is less favourable in patients submitted to clinical treatment in the acute phase.

[Coronary angioplasty of moderate lesions (50 to 60%)]. / Angioplastia coronária de lesões moderadas (50 A 60%).

PURPOSE: To assess the efficacy of transluminal coronary angioplasty in patients with moderate (50-60%) coronary lesions. PATIENTS AND METHODS: One hundred and thirty nine patients, 108 (78%) male, mean age was 55 years, who underwent coronary angioplasty from August 1983 to January 1989. Clinical findings included stable angina in 91 (65%) and unstable angina in 48 (35%). Single vessel disease was the case for 117 (84%), whereas 22 (16%) had two vessel coronary artery disease. RESULTS: Primary success rate was 130 (94%). All patients with two vessel disease had complete revascularization. In the failure group there were 2 acute myocardial infarction (1.4%), and 4 (2.8%) emergency coronary artery by-pass surgery. There were no in-hospital deaths. Of the 130 patients with success, 119 (92%) had late follow-up (mean time 31 months). At the end of the follow-up period we found 85 (71%) asymptomatic, while 27 (23%) had recurrence of symptoms. There were 2 late cardiovascular deaths. Fifty four patients underwent late angiography and 42 (78%) had maintenance of the result while 12 (22%) had restenosis, with a mean degree more severe than pre-coronary angioplasty. CONCLUSION: Coronary angioplasty of moderate lesions has a high success rate (94%); nevertheless the rate of major complications and restenosis is very similar to that of coronary angioplasty for severe stenosis. Such findings led us to reserve the indication of coronary angioplasty for moderate lesions for patients at higher risk with clear evidence of myocardial ischemia.

[The usefulness of digital angiography in performing coronary angioplasty. An analysis of 100 cases]. / Utilidade da angiografia digital na realização da angioplastia coronária. Análise de 100 casos.

PURPOSE: To analyse the actual contribution of digital angiography in the angioplasty setting and to assess its utility to optimize angioplasty results. METHODS: One hundred patients with single vessel coronary artery disease, without previous angioplasty or coronary artery bypass graft surgery, who underwent angioplasty from January to December 1990. Views were obtained in standard films and also in digitized angiograms. The latter was acquired before angioplasty in order to precisely quantify the stenosis and also to measure the reference diameter of the artery that was used and to choose the balloon catheter for each case. New acquisitions were done during and after the end of the procedure to confirm the residual stenosis and to measure the final diameter. RESULTS: The mean stenosis pre angioplasty was 78.2%, the mean reference diameter 2.8 mm and the mean diameter at the stenotic site 0.8 mm. The balloon artery relation was 0.9:1. After angioplasty the residual stenosis was 13.6% and the dilated segment had a final diameter of 2.6 mm. There were no complications in any patient. CONCLUSION: Digital angiography is a useful method for laboratories devoted to coronary interventions for it allows confirmation of the severity of the stenosis, optimizes the balloon/artery relation, monitors partial results and measures the residual stenosis as well as the final diameter.

[Intracoronary isosorbide mononitrate versus placebo. A double-blind study with quantitative coronary angiography]. / Mononitrato de isossorbida intracoronário versus placebo. Estudo duplo-cego através da angiografia coronária quantitativa.

PURPOSE: To evaluate the vasodilation effect of intracoronary isosorbide mononitrate (ISMN) on the coronary arteries, systolic aortic pressure (SAP) and cardiac rhythms. METHODS: Forty patients aged 61 (40-72) years, 30 (75%) male, were randomized to receive on a double blind fashion, 20 mg of ISMN or placebo. The two groups had similar baseline characteristics. Quantitative coronary arteriography [by cardiovascular measurement system (CMS)] and SAP were compared before and after ISMN. We also observed the cardiac rhythm. RESULTS: There were no arrhythmias. Reference vessel diameter increased from 2.6 +/- 0.5 mm before to 2.9 +/- 0.4 mm after ISMN and did not change, mean 2.9 +/- 0.5 mm, before and after placebo. There was a difference between ISMN and placebo (p < 0.0001). There was no difference in the SAP change between the two groups, 4.2 +/- 0.7 mmHg with ISMN and 1.8 +/- 0.5 mmHg with placebo (p = NS). CONCLUSION: ISMN promotes a safe and effective vasodilation of the coronary arteries with no major effects in cardiac rhythm and systolic aortic pressure.

[Coronary arteriography with a very low profile catheter: efficacy and safety of the procedure and of the 60 minute hospital discharge]. / Arteriografia coronária com cateter de muito baixo perfil. Eficácia e segurança do procedimento e da alta hospitalar aos 60 minutos.

PURPOSE: To evaluate the feasibility, efficacy and safety of the use of 4F Judkins catheters for coronary angiography. METHODS: From August/95 to January/96, 70 patients with suspected coronary artery disease underwent coronary cineangiography by the Judkins technique, with 4F catheters. Following puncture of the right femoral artery, 4F sheaths were introduced. At the end of the procedure, the sheath was removed and manual compression was applied for 15 min. Patients were oriented to walk under specialized supervision, 60 min after the procedure, and discharged after 4h. RESULTS: Thirty nine (56%) patients were male, the age ranged from 31 to 83 (mean 57) years and weight from 43 to 101 (mean 69) kg. Optimal quality images were obtained in 62 patients (88%). It was necessary to use larger caliber catheters (6 and 8F) in 8 patients, due to femoral tortuosity or inadequate opacification of coronary arteries. There were no vascular complications nor major bleedings. In only 2 cases (3%) there was a minor bleeding, treated by new local compression. Sixty (85%) patients walked after 60 +/- 5 min and were discharged after 4h. CONCLUSION: The use of 4F catheters for coronary angiography by femoral approach allowed early deambulation with no major bleeding. Image quality was good, with little contrast used and short hospital stay. This technique may lead to a simpler less traumatic and less invasive coronary angiography.

Safety and efficacy of coronary stent implantation. Acute and six month outcomes of 1,126 consecutive patients treated in 1996 and 1997.

PURPOSE: The authors analyzed the 30-day and 6-month outcomes of 1,126 consecutive patients who underwent coronary stent implantation in 1996 and 1997. METHODS: The 30-day results and 6-month angiographic follow-up were analyzed in patients treated with coronary stents in 1996 and 1997. All patients underwent coronary stenting with high-pressure implantation (> 12 atm) and antiplatelet drug regimen (aspirin plus ticlopidine). RESULTS: During the study period, 1,390 coronary stents were implanted in 1,200 vessels of 1,126 patients; 477 patients were treated in the year 1996 and 649 in 1997. The number of percutaneous procedures performed using stents increased significantly in 1997 compared to 1996 (64% vs 48%, p = 0.0001). The 30-day results were similar in both years: the success and stent thrombosis rates were equal (97% and 0.8%, respectively). The occurrence of new Q wave MI (1.3% vs 1.1%, 1996 vs 1997, p = NS), emergency coronary bypass surgery (1% vs 0.6%, 1996 vs 1997, p = NS) and 30-day death rates (0.2% vs 0.5%, 1996 vs 1997, p = NS) were similar. The 6-month restenosis rate was 25% in 1996 and 27% in 1997 (p = NS); the target vessel revascularization rate was 15% in 1996 and 16% in 1997 (p = NS). CONCLUSIONS: Intracoronary stenting showed a high success rate and a low incidence of 30-day occurrence of new major coronary events in both periods, despite the greater angiographic complexity of the patients treated with in 1997. These adverse variables did not have a negative influence at the 6-month clinical and angiographic follow-up, with similar rates of restenosis and ischemia-driven target lesion revascularization rates.

[Angioplasty of the anterior descending artery with abnormal origin: use of a new low-profile catheter balloon. A case report]. / Angioplastia da artéria descendente anterior de origem anômala: aplicação de novo cateter-balão de baixo perfil. Relato de caso.

It is possible to perform transluminal coronary angioplasty (TCA) in thin vessels presenting severe obstructions. One of the achievements that made such procedure possible is the development of a new generation of balloon catheters. In this case report the TCA was performed in a very thin left anterior descending artery with an anomalous origin, a quite rare situation that represents a major problem to the traditional dilator system. The catheter used was a Probe (USCI), which differs of the traditional balloons in a number of characteristics. The authors consider the procedure in detail pointing out the advantages of using of the new generations and discuss the impact that newer technological developments will have in enlarging the indications for TCA and improving the results.

The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry--CENIC. Central Nacional de Intervenções Cardiovasculares.

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

Acute myocardial infarction in progressively elderly patients. A comparative analysis of immediate results in patients who underwent primary percutaneous coronary intervention.

OBJECTIVE: Analysis of the in-hospital results, in progressively elderly patients who undergo primary percutaneous coronary intervention (PCI) in the first 24 hours of AMI. METHODS: The patients were divided into three different age groups (60/69, 70/79, and > or =80 years) and were treated from 7/95 until 12/99. The primary success rate and the occurrence of major clinical events were analyzed at the end of the in-hospital phase. Coronary stent implantation and abciximab use were employed at the interventionist discretion. RESULTS: We analyzed 201 patients with age ranging from 60 to 93 years, who underwent primary PCI. Patients with ages above 70 were more often female (p=.015). Those with ages above 80 were treated later with PCI (p=.054), and all of them presented with total occlusion of the infarct-related artery. Coronary stents were implanted in 30% of the patients. Procedural success was lower in > or =80 year old patients (p=.022), and the death rate was higher in > or =70 years olds (p=.019). Reinfarction and coronary bypass surgery were uncommon events. A trend occurred toward a higher combined incidence of major in-hospital events according to increased age (p=.064). CONCLUSION: Elderly patients (> or =70 years) presented with adverse clinical and angiographic profiles and patients > or =80 years of age obtained reduced TIMI 3 flow success rates after primary PTCA, and those > or =70 years had a higher death rate.

[Heparin in coronary angioplasty. Randomized study in cases with low risk of acute occlusion]. / Heparina na angioplastia coronária. Estudo randomizado em casos com baixo risco para lclusão aguda.

PURPOSE: To assess the efficacy of heparin in preventing the abrupt closure after coronary angioplasty in low risk patients for this phenomenon. METHODS: In the last 4 years, 525 patients successfully dilated were randomized to receive intravenous heparin (n = 264) or not (n = 261) after the angioplasty. The excluding criteria were contraindications for heparin and risk for abrupt closure (refractory unstable angina, primary coronary angioplasty in acute myocardial infarction, evidence of intracoronary thrombus, intimal tear after the procedure and cases of chronic total occlusions). Both heparin and non heparin groups were similar in respect to female sex (15% x 17%; p = NS), age over 70 years old (7% x 9%; p = NS), previous myocardial infarction (26% x 24%; p = NS), multi-vessel procedures (4% x 7%; p = NS, stable angina (40% x 46%; p = NS), unstable angina (52% x 48%; p = NS) and angioplasty after thrombolytic therapy (8% x 6%; p = NS). RESULTS: The overall incidence of abrupt closure was 2/525 (0.4%), with one case (0.4%) in each group. The in-hospital mortality was 1/525 (0.2%), which occurred in a non-heparin patient, due to a anterior myocardial infarction. Major complications occurred similarly in heparin and non-heparin groups (0.4%). Bleeding complications were observed more frequently in the heparin group (7% x 2%; p = 0.002). All of them were in the catheterization site and none required blood transfusion. Severe systemic bleeding were not observed. CONCLUSION: In patients regarded as low risk for abrupt closure, the incidence of this complication was really low (0.4%) and heparin probably do not prevent it.

[Nonsurgical treatment of coronary pulmonary arteriovenous fistula]. / Tratamento não-cirúrgico de fístula artério-venosa coronária pulmonar.

Fifty eight year old man, with dyspnea, fatigue and progressive angina underwent cinecoronarography, which showed an arterio-venous coronary-pulmonary fistula originating from the circumflex artery to the pulmonary circulation. We decided to occlude it percutaneously, using a detachable balloon technic. The occlusion was accomplished successfully. Clinical evolution was excellent and the follow-up cinecoronarography 6 months later showed the maintainance of the initial results.

[Inefficacy of diltiazem in restenosis prevention after coronary angioplasty]. / Ineficácia do diltiazem na prevenção da reestenose após angioplastia coronária.

PURPOSE: To evaluate the efficacy of diltiazem in preventing restenosis after balloon angioplasty (PTCA). METHODS: Eighty-nine patients who were undergone to successful PTCA, were divided them in 2 groups (G): A) 44 patients (50%) who received diltiazem (180 mg tid) immediately after PTCA and were kept on it for 6 months); B) 45 patients (50%) who received placebo. Fifty two lesions were dilated in GA and 54 in GB. Patients were excluded from analysis for several reasons, including: necessity of diltiazem or others calcium channel blockers use; heart failure, bradicardia, AV block of any degree, PTCA to chronic total occlusion, ostial lesions and AMI less than 30 days prior to PTCA. Patients were randomized to either the active drug or placebo in a double blind fashion. Restenosis was defined as a 50% lesion. Patients underwent late angiography either at 6 months or sooner if clinically indicated. RESULTS: Both G were similar to age > 70 years (A = 7% vs B = 4%-p = NS), sex (A = 13% vs B = 11%-p = NS), stable angina (A = 43% vs B = 51%), unstable angina (A = 57% vs B = 49%-p = NS) and single vessel (A = 91% vs B = 87%-p = NS) or multivessel (A = 9% vs B = 13%-p = NS) PTCA. We studied 39/44 (89%) patients in GA and 43/45 (96%) in GB (p = NS). We observed restenosis in 17/39 (43%) in GA and 16/43 (37%) in GB (p = NS). The restenosis rate per lesion was 39% in GA and 31% in GB (p = NS). CONCLUSION: Diltiazem was ineffective in the prevention of restenosis following PTCA.

[Current complications of heart catheterization. Analysis of 100 cases]. / Complicações atuais do cateterismo cardíaco. Análise de 1000 pacientes.

PURPOSE: To analyse the impact of the new cardiac catheterization techniques on the complication profile of these procedures. PATIENTS AND METHODS: One thousand consecutive patients who underwent cardiac catheterization from August through December, 1989 (739 diagnostic and 201 therapeutic procedures), who were followed up until hospital discharge. Complications were classified accordingly to their type and severity, and were related to the procedure employed and to the left ventricular ejection fraction. RESULTS: There were no complications in 77.7% of the population studied. In the remaining 236 patients the incidence of mild, moderate and severe complications were, respectively: 11.2%, 7.3% and 3.8%. Severe vascular complications occurred in 0.5%, cardiac perforation requiring emergency surgical repair in 0.1%, severe arrhythmias in 1.4%, acute myocardial infarction in 0.4%, acute pulmonary edema in 0.3% and fatal events in 0.5% patients. CONCLUSION: Despite the increasing application of interventional techniques and the greater number of acutely ill patients referred to cardiac catheterization, these procedures have proved to be safe with a low complication rate.