RESUMO
There does not appear to be a difference in patient outcomes of percutaneous coronary intervention for unprotected left main coronary artery stenosis whether using first- or second-generation drug elutting stent. This is despite increase in patients having more adjunctive procedures such as intravascular imaging and newer generation antiplatelet agents. This single-center study provokes questions as to why there has not been improvement in outcomes.
Assuntos
Estenose Coronária , Stents Farmacológicos , Intervenção Coronária Percutânea , Características da Família , Humanos , Pacientes , Stents , Resultado do TratamentoRESUMO
The use of mechanical thrombectomy in STEMI with large amount of jeopardized myocardium may preserve regional wall motion When appropriate and done with proper removal technique, there does not appear to be any increased incidence of neurologic complications The guideline recommendation that mechanical thrombectomy should not be done routinely is supported by these authors.
Assuntos
Infarto do Miocárdio , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Miocárdio , Sistema de Registros , TrombectomiaRESUMO
The learning curve for TAVR is determined based on technical (procedural) data from PARTNER-1 Trial The number of cases needed to reach a learning curve for TAVR in PARTNER-1 was 50 for original sites and fell to 25 for late entering sites Analyses such as this is important in developing guidelines for other emerging technologies.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Educação de Pós-Graduação em Medicina/normas , Próteses Valvulares Cardíacas , Curva de Aprendizado , Ensino/normas , Substituição da Valva Aórtica Transcateter/educação , Artéria Femoral , Humanos , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/métodosRESUMO
Current guidelines indicate that routine aspiration thrombectomy (AT) has a level III indication and AT is only indicated for "bail-out" indications. "Bail-out" situations are not well defined. The AT catheter may still be necessary and have other uses such as distal contrast or drug delivery.
Assuntos
Sucção , Trombectomia , Catéteres , Humanos , Resultado do TratamentoRESUMO
With the evolution of transcatheter valve replacement, an important opportunity has arisen for cardiologists and surgeons to collaborate in identifying the criteria for performing these procedures. Therefore, The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), and The Society of Thoracic Surgeons (STS) have partnered to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns transcatheter pulmonic valve replacement (tPVR). tPVR procedures are in their infancy with few reports available on which to base an expert consensus statement. Therefore, many of these recommendations are based on expert consensus and the few reports available. As the procedures evolve, technology advances, experience grows, and more data accumulate, there will certainly be a need to update this consensus statement. The writing committee and participating societies believe that the recommendations in this report serve as appropriate requisites. In some ways, these recommendations apply to institutions more than to individuals. There is a strong consensus that these new valve therapies are best performed using a Heart Team approach; thus, these credentialing criteria should be applied at the institutional level. Partnering societies used the ACC's policy on relationships with industry (RWI) and other entities to author this document (http://www.acc.org/guidelines/about-guidelines-and-clinical-documents). To avoid actual, potential, or perceived conflicts of interest due to industry relationships or personal interests, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current healthcare-related relationships including those existing 12 months before the initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI and to be led by an interventional cardiology cochair and a surgical cochair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in the Appendices. In addition, to ensure complete transparency, authors' comprehensive disclosure information (including RWI not pertinent to this document) is available in Appendix AII. The work of the writing committee was supported exclusively by the partnering societies without commercial support. SCAI, AATS, ACC, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.
Assuntos
Cateterismo Cardíaco/normas , Cardiologia/normas , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/normas , Guias de Prática Clínica como Assunto , Valva Pulmonar/cirurgia , Sociedades Médicas , American Heart Association , Humanos , Estados UnidosAssuntos
Valva Aórtica/cirurgia , Medicina Baseada em Evidências/normas , Doenças das Valvas Cardíacas/cirurgia , Próteses Valvulares Cardíacas/normas , Padrões de Prática Médica/normas , Substituição da Valva Aórtica Transcateter/normas , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Técnicas de Imagem Cardíaca/normas , Competência Clínica/normas , Tomada de Decisão Clínica , Consenso , Credenciamento/normas , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/fisiopatologia , Hemodinâmica , Humanos , Curva de Aprendizado , Seleção de Pacientes , Valor Preditivo dos Testes , Desenho de Prótese/normas , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Resultado do Tratamento , Carga de Trabalho/normasAssuntos
Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Eletrocardiografia , Medicina Baseada em Evidências , Humanos , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombectomia/métodos , Resultado do TratamentoAssuntos
American Heart Association , Cardiologia/normas , Angiografia Coronária/normas , Intervenção Coronária Percutânea/normas , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Sociedades Médicas , Humanos , Estados UnidosRESUMO
As the prevalence of asymptomatic COVID-19 continues to increase, there is an increasing possibility that patients with COVID-19 may presen with ST-segment elevation myocardial infarction (STEMI). With social distancing and restricted access to preventive healthcare and emergency services, the management of acute cardiac emergencies such as myocardial infarction has suffered collateral damage. Thus far, global trends suggest a decrease in STEMI activations with possible worse outcomes due to delayed presentation and management. In this review, we discuss the challenges to STEMI management in the COVID-19 era and provide potential solutions for adherence to evidence-based therapies as the pandemic progresses into the year 2021.
Assuntos
COVID-19/complicações , Controle de Infecções/organização & administração , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , COVID-19/epidemiologia , COVID-19/prevenção & controle , Humanos , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologiaRESUMO
OBJECTIVES: The aim of this study was to evaluate 1-year outcomes of valve-in-mitral annular calcification (ViMAC) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial. BACKGROUND: The MITRAL trial is the first prospective study evaluating the feasibility of ViMAC using balloon-expandable aortic transcatheter heart valves. METHODS: A multicenter prospective study was conducted, enrolling high-risk surgical patients with severe mitral annular calcification and symptomatic severe mitral valve dysfunction at 13 U.S. sites. RESULTS: Between February 2015 and December 2017, 31 patients were enrolled (median age 74.5 years [interquartile range (IQR): 71.3 to 81.0 years], 71% women, median Society of Thoracic Surgeons score 6.3% [IQR: 5.0% to 8.8%], 87.1% in New York Heart Association functional class III or IV). Access was transatrial (48.4%), transseptal (48.4%), or transapical (3.2%). Technical success was 74.2%. Left ventricular outflow tract obstruction (LVOTO) with hemodynamic compromise occurred in 3 patients (transatrial, n = 1; transseptal, n = 1; transapical, n = 1). After LVOTO occurred in the first 2 patients, pre-emptive alcohol septal ablation was implemented to decrease risk in high-risk patients. No intraprocedural deaths or conversions to open heart surgery occurred during the index procedures. All-cause mortality at 30 days was 16.7% (transatrial, 21.4%; transseptal, 6.7%; transapical, 100% [n = 1]; p = 0.33) and at 1 year was 34.5% (transatrial, 38.5%; transseptal, 26.7%; p = 0.69). At 1-year follow-up, 83.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.1 mm Hg (IQR: 5.6 to 7.1 mm Hg), and all patients had ≤1+ mitral regurgitation. CONCLUSIONS: At 1 year, ViMAC was associated with symptom improvement and stable transcatheter heart valve performance. Pre-emptive alcohol septal ablation may prevent transcatheter mitral valve replacement-induced LVOTO in patients at risk. Thirty-day mortality of patients treated via transseptal access was lower than predicted by the Society of Thoracic Surgeons score. Further studies are needed to evaluate safety and efficacy of ViMAC.
Assuntos
Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência da Valva Mitral , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Feminino , Humanos , Masculino , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to assess 1-year clinical outcomes among high-risk patients with failed surgical mitral bioprostheses who underwent transseptal mitral valve-in-valve (MViV) with the SAPIEN 3 aortic transcatheter heart valve (THV) in the MITRAL (Mitral Implantation of Transcatheter Valves) trial. BACKGROUND: The MITRAL trial is the first prospective study evaluating transseptal MViV with the SAPIEN 3 aortic THV in high-risk patients with failed surgical mitral bioprostheses. METHODS: High-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis due to failed surgical mitral bioprostheses were prospectively enrolled. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade ≥2+ or mean mitral valve gradient ≥10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year). RESULTS: Thirty patients were enrolled between July 2016 and October 2017 (median age 77.5 years [interquartile range (IQR): 70.3 to 82.8 years], 63.3% women, median Society of Thoracic Surgeons score 9.4% [IQR: 5.8% to 12.0%], 80% in New York Heart Association functional class III or IV). The technical success rate was 100%. The primary performance endpoint in survivors was achieved in 96.6% (28 of 29) at 30 days and 82.8% (24 of 29) at 1 year. Thirty-day all-cause mortality was 3.3% and was unchanged at 1 year. The only death was due to airway obstruction after swallowing several pills simultaneously 29 days post-MViV. At 1-year follow-up, 89.3% of patients were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.6 mm Hg (interquartile range: 5.5 to 8.9 mm Hg), and all patients had MR grade ≤1+. CONCLUSIONS: Transseptal MViV in high-risk patients was associated with 100% technical success, low procedural complication rates, and very low mortality at 1 year. The vast majority of patients experienced significant symptom alleviation, and THV performance remained stable at 1 year.
Assuntos
Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Anuloplastia da Valva Mitral , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Estudos Prospectivos , Desenho de Prótese , Resultado do TratamentoRESUMO
OBJECTIVES: The authors report 1-year outcomes of high-risk patients with failed surgical annuloplasty rings undergoing transseptal mitral valve-in-ring (MViR) with the SAPIEN 3 aortic transcatheter heart valve (THV). BACKGROUND: The MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective study evaluating transseptal MViR with the SAPIEN 3 aortic THV in high-risk patients with failed surgical annuloplasty rings. METHODS: Prospective enrollment of high-risk patients with symptomatic moderate to severe or severe mitral regurgitation (MR) or severe mitral stenosis and failed annuloplasty rings at 13 U.S. sites. The primary safety endpoint was technical success. The primary THV performance endpoint was absence of MR grade ≥2+ or mean mitral valve gradient ≥10 mm Hg (30 days and 1 year). Secondary endpoints included procedural success and all-cause mortality (30 days and 1 year). RESULTS: Thirty patients were enrolled between January 2016 and October 2017 (median age 71.5 years [interquartile range: 67.0 to 76.8 years], 36.7% women, median Society of Thoracic Surgeons score 7.6% [interquartile range: 5.1% to 11.8%], 76.7% in New York Heart Association functional class III or IV). Technical success was 66.7% (driven primarily by need for a second valve in 6 patients). There was no intraprocedural mortality or conversion to surgery. The primary performance endpoint was achieved in 85.7% of survivors at 30 days (24 of 28) and 89.5% of patients alive at 1 year with echocardiographic data available (17 of 19). All-cause mortality at 30 days was 6.7% and at 1 year was 23.3%. Among survivors at 1-year follow-up, 84.2% were in New York Heart Association functional class I or II, the median mean mitral valve gradient was 6.0 mm Hg (interquartile range: 4.7 to 7.3 mm Hg), and all had ≤1+ MR. CONCLUSIONS: Transseptal MViR was associated with a 30-day mortality rate lower than predicted by the Society of Thoracic Surgeons score. At 1 year, transseptal MViR was associated with symptom improvement and stable THV performance.
Assuntos
Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Idoso , Cateterismo Cardíaco/efeitos adversos , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Estudos Prospectivos , Desenho de Prótese , Resultado do TratamentoRESUMO
BACKGROUND: Transcatheter mitral valve replacement using aortic transcatheter heart valves has recently become an alternative for patients with degenerated mitral bioprostheses, failed surgical repairs with annuloplasty rings or severe mitral annular calcification who are poor surgical candidates. Outcomes of these procedures are collected in the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry. A comprehensive analysis of mitral valve-in-valve (MViV), mitral valve-in-ring (MViR), and valve-in-mitral annular calcification (ViMAC) outcomes has not been performed. We sought to evaluate short-term outcomes of early experience with MViV, MViR, and ViMAC in the United States. METHODS: Retrospective analysis of data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. RESULTS: Nine hundred three high-risk patients (median Society of Thoracic Surgeons score 10%) underwent MViV (n=680), MViR (n=123), or ViMAC (n=100) between March 2013 and June 2017 at 172 hospitals. Median age was 75 years, 59.2% female. Technical and procedural success were higher in MViV. Left ventricular outflow tract obstruction occurred more frequently with ViMAC (ViMAC=10%, MViR=4.9%, MViV=0.7%; P<0.001). In-hospital mortality (MViV=6.3%, MViR=9%, ViMAC=18%; P=0.004) and 30-day mortality (MViV=8.1%, MViR=11.5%, ViMAC=21.8%; P=0.003) were higher in ViMAC. At 30-day follow-up, median mean mitral valve gradient was 7 mm Hg, most patients (96.7%) had mitral regurgitation grade ≤1 (+) and were in New York Heart Association class I to II (81.7%). CONCLUSIONS: MViV using aortic balloon-expandable transcatheter heart valves is associated with a low complication rate, a 30-day mortality lower than predicted by the Society of Thoracic Surgeons score, and superior short-term outcomes than MViR and ViMAC. At 30 days, patients in all groups experienced improvement of symptoms, and valve performance remained stable. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02245763.
Assuntos
Calcinose/cirurgia , Cateterismo Cardíaco/instrumentação , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Anuloplastia da Valva Mitral/instrumentação , Valva Mitral/cirurgia , Falha de Prótese , Idoso , Idoso de 80 Anos ou mais , Calcinose/etiologia , Calcinose/mortalidade , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Feminino , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Masculino , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/mortalidade , Desenho de Prótese , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosAssuntos
Infarto do Miocárdio/terapia , Reperfusão Miocárdica/métodos , Intervenção Coronária Percutânea , Medição de Risco , Terapia Trombolítica , American Heart Association , Cardiologia/métodos , Cardiologia/normas , Protocolos Clínicos/classificação , Protocolos Clínicos/normas , Técnicas de Diagnóstico Cardiovascular , Gerenciamento Clínico , Eletrocardiografia , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Humanos , Conduta do Tratamento Medicamentoso/normas , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Seleção de Pacientes , Estados UnidosAssuntos
Cateterismo Cardíaco/normas , Cardiologia/normas , Implante de Prótese de Valva Cardíaca/normas , Insuficiência da Valva Mitral/terapia , Cirurgia Torácica/normas , Cateterismo Cardíaco/efeitos adversos , Cardiologia/educação , Protocolos Clínicos , Diagnóstico por Imagem , Educação de Pós-Graduação em Medicina , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Insuficiência da Valva Mitral/diagnóstico , Seleção de Pacientes , Valor Preditivo dos Testes , Fatores de Risco , Cirurgia Torácica/educação , Resultado do TratamentoRESUMO
Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same-day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention.
Assuntos
Assistência Ambulatorial/normas , Angioplastia Coronária com Balão/normas , Tempo de Internação , Alta do Paciente/normas , Qualidade da Assistência à Saúde/normas , Assistência Ambulatorial/economia , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/economia , Competência Clínica , Protocolos Clínicos , Custos de Cuidados de Saúde , Instalações de Saúde/normas , Humanos , Reembolso de Seguro de Saúde , Tempo de Internação/economia , Observação , Alta do Paciente/economia , Qualidade da Assistência à Saúde/economia , Medição de Risco , Terminologia como Assunto , Resultado do TratamentoAssuntos
Cateterismo Cardíaco/normas , Cardiologia/normas , Certificação/normas , Competência Clínica/normas , Instalações de Saúde/normas , Doenças das Valvas Cardíacas/terapia , Implante de Prótese de Valva Cardíaca/normas , Valva Mitral , Cateterismo Cardíaco/efeitos adversos , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/fisiopatologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Privilégios do Corpo Clínico/normas , Valva Mitral/fisiopatologia , Equipe de Assistência ao Paciente/normas , Formulação de Políticas , Desenvolvimento de Programas/normas , Resultado do TratamentoRESUMO
UNLABELLED: Doctor: "Ma'am you need an angioplasty". PATIENT: "Doctor, the newspaper says that medicine is as good as angioplasty". Doctor: "Ma'am you're having a heart attack". The COURAGE trial was published 1 year ago and received attention from the media, patients, and other medical specialties concerning the value of percutaneous coronary intervention. Now, 1 year later there has been time to reflect on COURAGE, and some newer data have emerged. The purpose of this article is to put into perspective the issues surrounding the COURAGE trial and suggest different approaches for future trials of stable coronary artery disease.