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1.
Circulation ; 145(3): e4-e17, 2022 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-34882436

RESUMO

AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.


Assuntos
Cardiologia/normas , Ponte de Artéria Coronária/normas , Revascularização Miocárdica/normas , Intervenção Coronária Percutânea/normas , Procedimentos Cirúrgicos Vasculares/normas , American Heart Association/organização & administração , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Vasos Coronários/cirurgia , Humanos , Estados Unidos , Procedimentos Cirúrgicos Vasculares/métodos
2.
Circulation ; 144(2): e16-e35, 2021 07 13.
Artigo em Inglês | MEDLINE | ID: mdl-34126755

RESUMO

Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.


Assuntos
Infarto do Miocárdio/complicações , Doença Aguda , American Heart Association , Humanos , Infarto do Miocárdio/patologia , Estados Unidos
3.
Circulation ; 141(2): e6-e32, 2020 01 14.
Artigo em Inglês | MEDLINE | ID: mdl-31813278

RESUMO

Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.


Assuntos
Doenças Cardiovasculares/patologia , Avaliação Geriátrica , Idoso , American Heart Association , Doenças Cardiovasculares/terapia , Tomada de Decisões , Delírio/patologia , Gerenciamento Clínico , Ingestão de Energia , Fragilidade , Humanos , Unidades de Terapia Intensiva , Pessoa de Meia-Idade , Multimorbidade , Polimedicação , Prognóstico , Fatores de Risco , Cuidado Transicional , Estados Unidos
4.
Catheter Cardiovasc Interv ; 98(2): 217-222, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32767652

RESUMO

OBJECTIVE: To evaluate the impact of COVID-19 pandemic migitation measures on of ST-elevation myocardial infarction (STEMI) care. BACKGROUND: We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID-19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data. METHODS: Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019-February 2020 and March-April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC. RESULTS: Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18-38, p < .001), number of activations leading to angiography (34%, 95% CI: 12-50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11-27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (-0.2 to 44, p = .05). CONCLUSIONS: The COVID-19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI.


Assuntos
Angioplastia Coronária com Balão/estatística & dados numéricos , COVID-19/epidemiologia , Intervenção Coronária Percutânea/estatística & dados numéricos , Sistema de Registros , SARS-CoV-2 , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Comorbidade , Feminino , Seguimentos , Humanos , Masculino , Pandemias , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Fatores de Tempo , Estados Unidos/epidemiologia
5.
Catheter Cardiovasc Interv ; 98(5): 904-913, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34398509

RESUMO

The Society for Cardiovascular Angiography and Interventions (SCAI) Think Tank is a collaborative venture that brings together interventional cardiologists, administrative partners, and select members of the cardiovascular industry community annually for high-level field-wide discussions. The 2021 Think Tank was organized into four parallel sessions reflective of the field of interventional cardiology: (a) coronary intervention, (b) endovascular medicine, (c) structural heart disease, and (d) congenital heart disease. Each session was moderated by a senior content expert and co-moderated by a member of SCAI's Emerging Leader Mentorship program. This document presents the proceedings to the wider cardiovascular community in order to enhance participation in this discussion, create additional dialog from a broader base, and thereby aid SCAI, the industry community and external stakeholders in developing specific action items to move these areas forward.


Assuntos
Cardiologistas , Cardiologia , Cardiopatias Congênitas , Angiografia , Humanos , Resultado do Tratamento
6.
Circulation ; 139(4): 458-472, 2019 01 22.
Artigo em Inglês | MEDLINE | ID: mdl-30586696

RESUMO

BACKGROUND: Although many studies show an inverse association between operator procedural volume and short-term adverse outcomes after percutaneous coronary intervention (PCI), the association between procedural volume and longer-term outcomes is unknown. METHODS: Using the National Cardiovascular Data Registry CathPCI registry data linked with Medicare claims data, we examined the association between operator PCI volume and long-term outcomes among patients ≥65 years of age. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (<50 PCIs), intermediate- (50-100), and high- (>100) volume operators. One-year unadjusted rates of death and major adverse coronary events (MACEs; defined as death, readmission for myocardial infarction, or unplanned coronary revascularization) were calculated with Kaplan-Meier methods. The proportional hazards assumption was not met, and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up. RESULTS: Between July 1, 2009, and December 31, 2014, 723 644 PCI procedures were performed by 8936 operators: 2553 high-, 2878 intermediate-, and 3505 low-volume operators. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI, and their patients had fewer cardiovascular comorbidities. Over 1-year follow-up, 15.9% of patients treated by low-volume operators had a MACE compared with 16.9% of patients treated by high-volume operators ( P=0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio, 0.91; 95% CI, 0.86-0.96 for intermediate versus low; odds ratio, 0.79; 95% CI, 0.75-0.83 for high versus low). There were no significant differences in rates of MACEs, death, myocardial infarction, or unplanned revascularization between operator cohorts from hospital discharge to 1-year follow-up (adjusted hazard ratio for MACEs, 0.99; 95% CI, 0.96-1.01 for intermediate versus low; hazard ratio, 1.01; 95% CI, 0.99-1.04 for high versus low). CONCLUSIONS: Unadjusted 1-year outcomes after PCI were worse for older adults treated by operators with higher annual volume; however, patients treated by these operators had more cardiovascular comorbidities. After risk adjustment, higher operator volume was associated with lower in-hospital mortality and no difference in postdischarge MACEs.


Assuntos
Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Intervenção Coronária Percutânea/tendências , Padrões de Prática Médica/tendências , Carga de Trabalho , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Medicare , Readmissão do Paciente/tendências , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Sistema de Registros , Retratamento/tendências , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
7.
Am Heart J ; 227: 9-10, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32640370

RESUMO

We aimed to investigate long-term (≥5 years) outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) using a meta-analysis from updated published randomized trials. Our data showed that the risk of all-cause death as well as cardiovascular death, myocardial infarction, and stroke was similar between PCI and CABG, whereas PCI had significantly higher rates of repeat revascularization compared to CABG. Decisions for PCI versus CABG for LMCAD should be based on weighing the upfront morbidity and mortality risk of CABG with late risk of repeat revascularization with PCI and taking into consideration patient preference.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do Tratamento
8.
Catheter Cardiovasc Interv ; 96(3): 586-597, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32212409

RESUMO

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly infectious, carries significant morbidity and mortality, and has rapidly resulted in strained health care system and hospital resources. In addition to patient-related care concerns in infected individuals, focus must also relate to diminishing community spread, protection of staff, case selection, and concentration of resources. The current document based on available data and consensus opinion addresses appropriate catheterization laboratory preparedness for treating these patients, including procedure-room readiness to minimize external contamination, safe donning and doffing of personal protective equipment (PPE) to eliminate risk to staff, and staffing algorithms to minimize exposure and maximize team availability. Case selection and management of both emergent and urgent procedures are discussed in detail, including procedures that may be safely deferred or performed bedside.


Assuntos
Cateterismo Cardíaco/estatística & dados numéricos , Angiografia Coronária/estatística & dados numéricos , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto/normas , COVID-19 , Cateterismo Cardíaco/normas , Cardiologia , Angiografia Coronária/métodos , Infecções por Coronavirus/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Laboratórios Hospitalares , Liderança , Masculino , Mentores , Pandemias/estatística & dados numéricos , Equipamento de Proteção Individual/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Sociedades Médicas , Análise de Sobrevida , Estados Unidos
9.
Stroke ; 50(8): 2125-2132, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31303150

RESUMO

Background and Purpose- The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods- PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results- Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions- Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.


Assuntos
Fibrilação Atrial/complicações , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Estenose Coronária/cirurgia , Humanos , Metanálise em Rede , Stents
10.
Am Heart J ; 218: 84-91, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31715434

RESUMO

Advanced age is directly related to worse outcomes following ST-elevation myocardial infarction (STEMI) and higher complication rates from antithrombotic therapies and primary percutaneous coronary intervention (PCI). Often excluded from clinical trials, seniors presenting with STEMI remain an understudied population despite contributing to 140,000 hospital admissions annually. The SAFE-STEMI for Seniors study is a prospective, multicenter, unblinded, randomized clinical trial designed to examine the efficacy and safety of instantaneous wave-free ratio-guided complete revascularization in multivessel disease, while also investigating other components of STEMI care for patients ≥60 years including the efficacy and safety of zotarolimus-eluting stents for primary PCI and transradial PCI with the Glidesheath Slender and TR band. The SAFE-STEMI trial represents North America's first and only prospective randomized investigational device exemption study to use a Coordinated Registry Network infrastructure with collaborative partnering across industry manufacturers, promoting both efficiency and reduced cost of evidence development for regulatory decisions related to both diagnostic and therapeutic technologies in a single study design. The study has been powered to evaluate 2 independent co-primary end points in a population of older patients with STEMI: (1) third-generation drug-eluting stents for primary PCI and (2) instantaneous wave-free ratio-guided complete revascularization versus infarct-related artery-only revascularization.


Assuntos
Stents Farmacológicos , Imunossupressores/uso terapêutico , Intervenção Coronária Percutânea/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Sirolimo/análogos & derivados , Idoso , Humanos , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Intervenção Coronária Percutânea/instrumentação , Estudos Prospectivos , Sirolimo/uso terapêutico , Resultado do Tratamento
11.
Catheter Cardiovasc Interv ; 93(3): 373-379, 2019 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-30280472

RESUMO

BACKGROUND: Despite improvements in acute care and survival after non-ST-elevation acute coronary syndrome (NSTE-ACS) hospitalization, early readmissions remain common, and have significant clinical and financial impact. OBJECTIVES: Determine the predictors and etiologies of 30-day readmissions in NSTE-ACS. METHOD: The study cohort was derived from the National Readmission Database 2014 identifying patients with a primary diagnosis of NSTE-ACS using ICD9 code. RESULTS: We identified a total of 300,269 patients admitted with NSTE-ACS; 13.4% were readmitted within 30-day. The most common cause of readmission was heart failure (HF) (15.6%), followed by a recurrent myocardial infarction (MI) (10%). Predictors of increased readmissions were age ≥ 75 years (OR: 1.34, 95% CI: 1.30-1.39), female gender (OR 1.12, 95% CI 1.09-1.16), a Charlson Comorbidity Index (CCI) >3 (OR 2.11, 95% CI: 2.04-2.18), ESRD (OR 2.01, 95% CI 1.89-2.14), CKD (OR: 1.58, 95% CI: 1.51-1.64), length of stay ≥5 days (OR: 1.51, 95% CI 1.46-1.56) and adverse events during the index admission such as AKI (OR:1.31, 95% CI: 1.25-1.36), major bleeding (OR:1.20, 95% CI: 1.12-1.24); whereas admission to a teaching hospital (OR 0.92, 95% CI 0.89-0.95) and PCI (OR 0.70, 95% CI 0.67-0.72) were associated with less likelihood of 30-day readmission. CONCLUSION: Readmission rate at 30-days is high among NSTE-ACS patients and the most common readmission etiologies are HF and recurrent MI. A CCI more than 3 and ESRD were the most significant predictors for readmission; patients undergoing PCI had less odds of readmission.


Assuntos
Síndrome Coronariana Aguda/terapia , Fármacos Cardiovasculares/uso terapêutico , Ponte de Artéria Coronária , Insuficiência Cardíaca/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Readmissão do Paciente , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Adolescente , Adulto , Idoso , Fármacos Cardiovasculares/efeitos adversos , Comorbidade , Bases de Dados Factuais , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Humanos , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Intervenção Coronária Percutânea/efeitos adversos , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
12.
Catheter Cardiovasc Interv ; 94(4): 578-587, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30790415

RESUMO

BACKGROUND: Pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) is the initial rhythm in a third of in-hospital cardiac arrest patients. Mechanical circulatory support (MCS) device use remains poorly understood in this population. METHODS: We conducted an observational analysis of temporal trends in the utilization of MCS in VT/VF IHCA between January 2008 and December 2014 utilizing the Nationwide Inpatient Sample (NIS) database. Using multivariable analysis, we assessed factors associated with MCS use and survival to discharge. RESULTS: Among 151,628 hospitalizations with VT/VF IHCA, 14,981 (9.9%) received MCS. Intra-aortic balloon pump (IABP) was the most commonly used MCS (9.1%). From 2008 to 2014, there was significant increase in the utilization of MCS (8.7-11%; ptrend < 0.0001). On multivariable analysis, there was 12-fold increase and three-fold increase in the utilization of PVAD and ECMO respectively; however, there was no significant change in the use of IABP. Over the seven-year sample period, there was significant increase in the overall survival to hospital discharge (35.4-43.5%; ptrend < 0.0001). Survival to hospital discharge increased in both MCS and non-MCS groups. CONCLUSION: There was significant increase in utilization of MCS after VT/VF IHCA during the study period. IABP was the most commonly utilized MCS. The survival to hospital discharge increased in the overall study population including both MCS and non-MCS groups. Future studies are needed to identify patient population most likely to benefit from the use of MCS after VT/VF IHCA.


Assuntos
Oxigenação por Membrana Extracorpórea/tendências , Parada Cardíaca/terapia , Coração Auxiliar/tendências , Balão Intra-Aórtico/tendências , Oxigenadores de Membrana/tendências , Padrões de Prática Médica/tendências , Taquicardia Ventricular/complicações , Fibrilação Ventricular/complicações , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/instrumentação , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/fisiopatologia
13.
Circ Res ; 121(11): 1279-1290, 2017 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-28923793

RESUMO

RATIONALE: Cell dose and concentration play crucial roles in phenotypic responses to cell-based therapy for heart failure. OBJECTIVE: To compare the safety and efficacy of 2 doses of allogeneic bone marrow-derived human mesenchymal stem cells identically delivered in patients with ischemic cardiomyopathy. METHODS AND RESULTS: Thirty patients with ischemic cardiomyopathy received in a blinded manner either 20 million (n=15) or 100 million (n=15) allogeneic human mesenchymal stem cells via transendocardial injection (0.5 cc per injection × 10 injections per patient). Patients were followed for 12 months for safety and efficacy end points. There were no treatment-emergent serious adverse events at 30 days or treatment-related serious adverse events at 12 months. The Major Adverse Cardiac Event rate was 20.0% (95% confidence interval [CI], 6.9% to 50.0%) in 20 million and 13.3% (95% CI, 3.5% to 43.6%) in 100 million (P=0.58). Worsening heart failure rehospitalization was 20.0% (95% CI, 6.9% to 50.0%) in 20 million and 7.1% (95% CI, 1.0% to 40.9%) in 100 million (P=0.27). Whereas scar size reduced to a similar degree in both groups: 20 million by -6.4 g (interquartile range, -13.5 to -3.4 g; P=0.001) and 100 million by -6.1 g (interquartile range, -8.1 to -4.6 g; P=0.0002), the ejection fraction improved only with 100 million by 3.7 U (interquartile range, 1.1 to 6.1; P=0.04). New York Heart Association class improved at 12 months in 35.7% (95% CI, 12.7% to 64.9%) in 20 million and 42.9% (95% CI, 17.7% to 71.1%) in 100 million. Importantly, proBNP (pro-brain natriuretic peptide) increased at 12 months in 20 million by 0.32 log pg/mL (95% CI, 0.02 to 0.62; P=0.039), but not in 100 million (-0.07 log pg/mL; 95% CI, -0.36 to 0.23; P=0.65; between group P=0.07). CONCLUSIONS: Although both cell doses reduced scar size, only the 100 million dose increased ejection fraction. This study highlights the crucial role of cell dose in the responses to cell therapy. Determining optimal dose and delivery is essential to advance the field, decipher mechanism(s) of action and enhance planning of pivotal Phase III trials. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02013674.


Assuntos
Cardiomiopatias/cirurgia , Transplante de Células-Tronco Mesenquimais/métodos , Infarto do Miocárdio/complicações , Disfunção Ventricular Esquerda/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Cardiomiopatias/etiologia , Cardiomiopatias/patologia , Cardiomiopatias/fisiopatologia , Feminino , Florida , Nível de Saúde , Humanos , Masculino , Transplante de Células-Tronco Mesenquimais/efeitos adversos , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Infarto do Miocárdio/fisiopatologia , Miocárdio/metabolismo , Miocárdio/patologia , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Qualidade de Vida , Recuperação de Função Fisiológica , Volume Sistólico , Fatores de Tempo , Transplante Homólogo , Resultado do Tratamento , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/patologia , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Adulto Jovem
14.
J Interv Cardiol ; 2019: 3276521, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31772523

RESUMO

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43-0.57; p < 0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06-1.34; p < 0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51-0.72; p < 0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.


Assuntos
Circulação Assistida/estatística & dados numéricos , Ponte Cardiopulmonar/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Registros Públicos de Dados de Cuidados de Saúde , Choque Cardiogênico/terapia , Idoso , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Estudos Retrospectivos , Choque Cardiogênico/mortalidade , Estados Unidos/epidemiologia
15.
Pacing Clin Electrophysiol ; 42(7): 846-852, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30977144

RESUMO

BACKGROUND: Complete heart block is a known complication after transcatheter aortic valve replacement (TAVR), often requiring pacemaker implantation within 24 hours of the procedure. However, clinical markers for delayed progression to complete heart block after TAVR remain unclear. OBJECTIVES: We examined electrocardiographic data that may correlate with delayed progression to complete heart block and need for pacemaker. METHODS: This is a single-center retrospective study of 608 patients who underwent TAVR between April 2008 and June 2017. We excluded 164 (27.0%) patients due to having a pacemaker before the procedure or expiring within 24 hours of the procedure (8, 1.3%). We excluded an additional 50 (8.2%) patients who received a pacemaker within 24 hours of the procedure. Electrocardiograms (EKGs) obtained after the procedure were compared to the preprocedural EKG to detect new changes. RESULTS: Left bundle branch block, intraventricular conduction delay, left anterior fascicular block, and right bundle branch block were the most commonly seen conduction abnormalities after TAVR (25.1%, 10.9%, 7.5%, and 3.6%, respectively). Both left bundle branch block (odds ratio [OR] = 2.77 [95% confidence interval (CI): 1.24-6.22]) and right bundle branch block (OR = 13.2 [95% CI: 4.18-41.70]) carried an increased risk of pacemaker implantation after TAVR. Additionally, ΔPR greater than 40 ms from baseline also carried an increased risk of pacemaker implantation (OR = 3.53 [95% CI: 1.49-8.37]). CONCLUSION: Left bundle branch block, right bundle branch block, and ΔPR greater than 40 ms were all associated with delayed progression to complete heart block and need for pacemaker implantation after TAVR.


Assuntos
Bloqueio Cardíaco/etiologia , Bloqueio Cardíaco/terapia , Marca-Passo Artificial , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Progressão da Doença , Eletrocardiografia , Feminino , Sistema de Condução Cardíaco/fisiopatologia , Humanos , Masculino , Estudos Retrospectivos
16.
Eur Heart J ; 39(8): 687-695, 2018 02 21.
Artigo em Inglês | MEDLINE | ID: mdl-29020413

RESUMO

Aims: There are limited data on coronary obstruction following transcatheter valve-in-valve (ViV) implantation inside failed aortic bioprostheses. The objectives of this study were to determine the incidence, predictors, and clinical outcomes of coronary obstruction in transcatheter ViV procedures. Methods and results: A total of 1612 aortic procedures from the Valve-in-Valve International Data (VIVID) Registry were evaluated. Data were subject to centralized blinded corelab computed tomography (CT) analysis in a subset of patients. The virtual transcatheter valve to coronary ostium distance (VTC) was determined. A total of 37 patients (2.3%) had clinically evident coronary obstruction. Baseline clinical characteristics in the coronary obstruction patients were similar to controls. Coronary obstruction was more common in stented bioprostheses with externally mounted leaflets or stentless bioprostheses than in stented with internally mounted leaflets bioprostheses (6.1% vs. 3.7% vs. 0.8%, respectively; P < 0.001). CT measurements were obtained in 20 (54%) and 90 (5.4%) of patients with and without coronary obstruction, respectively. VTC distance was shorter in coronary obstruction patients in relation to controls (3.24 ± 2.22 vs. 6.30 ± 2.34, respectively; P < 0.001). Using multivariable analysis, the use of a stentless or stented bioprosthesis with externally mounted leaflets [odds ratio (OR): 7.67; 95% confidence interval (CI): 3.14-18.7; P < 0.001] associated with coronary obstruction for the global population. In a second model with CT data, a shorter VTC distance predicted this complication (OR: 0.22 per 1 mm increase; 95% CI: 0.09-0.51; P < 0.001), with an optimal cut-off level of 4 mm (area under the curve: 0.943; P < 0.001). Coronary obstruction was associated with a high 30-day mortality (52.9% vs. 3.9% in the controls, respectively; P < 0.001). Conclusion: Coronary obstruction following aortic ViV procedures is a life-threatening complication that occurred more frequently in patients with prior stentless or stented bioprostheses with externally mounted leaflets and in those with a short VTC.


Assuntos
Oclusão Coronária/epidemiologia , Tomografia Computadorizada Multidetectores/métodos , Falha de Prótese/efeitos adversos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/etiologia , Feminino , Próteses Valvulares Cardíacas , Humanos , Incidência , Masculino , Análise Multivariada , Sistema de Registros , Fatores de Risco
17.
Circulation ; 136(16): e232-e268, 2017 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-28923988

RESUMO

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.


Assuntos
American Heart Association , Hemodinâmica , Choque Cardiogênico/terapia , Prestação Integrada de Cuidados de Saúde/organização & administração , Custos de Cuidados de Saúde , Humanos , Seleção de Pacientes , Fenótipo , Valor Preditivo dos Testes , Regionalização da Saúde/organização & administração , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Estados Unidos
19.
Catheter Cardiovasc Interv ; 92(6): 1205-1208, 2018 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-29469984

RESUMO

Aortic annular rupture is one of the most feared complications of transcatheter aortic valve replacement (TAVR). This complication often presents as sudden cardiac tamponade with hypotension and requires urgent intervention. The traditional rescue strategy for such cases is emergency surgical intervention, yet the mortality remains high considering most patients who undergo TAVR are not candidates for open heart surgery. As such, there is a need for percutaneous alternatives to treat this critical complication. Here, we describe a case of annular rupture during TAVR that was successfully treated with coil embolization at the rupture site. This case illustrates the use of coil embolization as a treatment strategy in patients with acute aortic annular rupture who are at high-risk for surgical intervention.


Assuntos
Estenose da Valva Aórtica/cirurgia , Tamponamento Cardíaco/terapia , Embolização Terapêutica/instrumentação , Traumatismos Cardíacos/terapia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Tamponamento Cardíaco/diagnóstico por imagem , Tamponamento Cardíaco/etiologia , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/etiologia , Humanos , Masculino , Resultado do Tratamento
20.
Catheter Cardiovasc Interv ; 92(5): 890-894, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29280545

RESUMO

OBJECTIVE: Examining the efficacy and outcomes of intracoronary (IC) instillation of adenosine using a novel perforated balloon technique (PBT) to combat no-reflow phenomenon during percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). BACKGROUND: Occurrence of no-reflow during PCI is a serious adverse prognostic event and inability to re-establish better flow is associated with poor outcomes. Several pharmacological and non-pharmacological interventions have been used to treat this situation. This series describes the use of PBT for IC adenosine administration and its effects on outcomes during real world interventional practice. METHODS: Subjects comprised of 24 patients with ACS (out of a total of 1,634 patients undergoing PCI between January 2016 and June 2017) in whom we used PBT for IC administration of adenosine to treat coronary no-reflow. RESULTS: PBT for IC adenosine instillation was used in 24 (1.5%) of 1,634 patients undergoing PCI. TIMI grade III flow was established in 21 patients (87.5%). In two patients (8.3%) TIMI grade II flow was established and in one patient (4.2%) we were unsuccessful. CONCLUSION: We demonstrate the safety and efficacy of a novel strategy for adenosine instillation in the distal coronary bed, the PBT. This technique enables rapid and cost-effective treatment of no-reflow phenomenon during PCI for ACS.


Assuntos
Síndrome Coronariana Aguda/terapia , Adenosina/administração & dosagem , Angioplastia Coronária com Balão/métodos , Circulação Coronária/efeitos dos fármacos , Fenômeno de não Refluxo/tratamento farmacológico , Vasodilatadores/administração & dosagem , Síndrome Coronariana Aguda/fisiopatologia , Adenosina/efeitos adversos , Adulto , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fenômeno de não Refluxo/etiologia , Fenômeno de não Refluxo/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Vasodilatadores/efeitos adversos
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