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Atrial cardiomyopathy has been recognized as having important consequences for cardiac performance and clinical outcomes. The pathophysiological role of the left atrial (LA) appendage and the effect of percutaneous left atrial appendage occlusion (LAAO) upon LA mechanics is incompletely understood. We evaluated if changes in LA stiffness due to endocardial LAAO can be detected by LA pressure-volume (PV) analysis and whether stiffness parameters are associated with baseline characteristics. Patients undergoing percutaneous endocardial LAAO (n = 25) were studied using a novel PV analysis using near-simultaneous three-dimensional LA volume measurements by transesophageal echocardiography (TEE) and direct invasive LA pressure measurements. LA stiffness (dP/dV, change in pressure with change in volume) was calculated before and after LAAO. Overall LA stiffness significantly increased after LAAO compared with baseline (median, 0.41-0.64 mmHg/mL; P ⪠0.001). LA body stiffness after LAAO correlated with baseline LA appendage size by indexed maximum depth (Spearman's rank correlation coefficient Rs = 0.61; P < 0.01). LA stiffness change showed an even stronger correlation with baseline LA appendage size by indexed maximum depth (Rs = 0.70; P < 0.001). We found that overall LA stiffness increases after endocardial LAAO. Baseline LA appendage size correlates with the magnitude of increase and LA body stiffness. These findings document alteration of LA mechanics after endocardial LAAO and suggest that the LA appendage modulates overall LA compliance.NEW & NOTEWORTHY Our study documents a correlation of LA appendage remodeling with the degree of chronically abnormal LA body stiffness. In addition, we found that LA appendage size was the baseline parameter that best correlated with the magnitude of a further increase in overall LA stiffness after appendage occlusion. These findings offer insights about the LA appendage and LA mechanics that are relevant to patients at risk for adverse atrial remodeling, especially candidates for LA appendage occlusion.
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Apêndice Atrial , Fibrilação Atrial , Acidente Vascular Cerebral , Doenças Vasculares , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/etiologia , Cateterismo Cardíaco , Ecocardiografia Transesofagiana/métodos , Humanos , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: Randomised trial data assessing the safety and efficacy of the self-expanding intra-annular Portico transcatheter aortic valve system (Abbott Structural Heart, St Paul, MN, USA) compared with any commercially available valves are needed to compare performance among designs. METHODS: In this prospective, multicentre, non-inferiority, randomised controlled trial (the Portico Re-sheathable Transcatheter Aortic Valve System US Investigational Device Exemption trial [PORTICO IDE]), high and extreme risk patients with severe symptomatic aortic stenosis were recruited from 52 medical centres experienced in performing transcatheter aortic valve replacement in the USA and Australia. Patients were eligible if they were aged 21 years or older, in New York Heart Association functional class II or higher, and had severe native aortic stenosis. Eligible patients were randomly assigned (1:1) using permuted block randomisation (block sizes of 2 and 4) and stratified by clinical investigational site, surgical risk cohort, and vascular access method, to transcatheter aortic valve replacement with the first generation Portico valve and delivery system or a commercially available valve (either an intra-annular balloon-expandable Edwards-SAPIEN, SAPIEN XT, or SAPIEN 3 valve [Edwards LifeSciences, Irvine, CA, USA]; or a supra-annular self-expanding CoreValve, Evolut-R, or Evolut-PRO valve [Medtronic, Minneapolis, MN, USA]). Investigational site staff, implanting physician, and study participant were unmasked to treatment assignment. Core laboratories and clinical event assessors were masked to treatment allocation. The primary safety endpoint was a composite of all-cause mortality, disabling stroke, life-threatening bleeding requiring transfusion, acute kidney injury requiring dialysis, or major vascular complication at 30 days. The primary efficacy endpoint was all-cause mortality or disabling stroke at 1 year. Clinical outcomes and valve performance were assessed up to 2 years after the procedure. Primary analyses were by intention to treat and the Kaplan-Meier method to estimate event rates. The non-inferiority margin was 8·5% for primary safety and 8·0% for primary efficacy endpoints. This study is registered with ClinicalTrials.gov, NCT02000115, and is ongoing. FINDINGS: Between May 30 and Sept 12, 2014, and between Aug 21, 2015, and Oct 10, 2017, with recruitment paused for 11 months by the funder, we recruited 1034 patients, of whom 750 were eligible and randomly assigned to the Portico valve group (n=381) or commercially available valve group (n=369). Mean age was 83 years (SD 7) and 395 (52·7%) patients were female. For the primary safety endpoint at 30 days, the event rate was higher in the Portico valve group than in the commercial valve group (52 [13·8%] vs 35 [9·6%]; absolute difference 4·2, 95% CI -0·4 to 8·8 [upper confidence bound {UCB} 8·1%]; pnon-inferiority=0·034, psuperiority=0·071). At 1 year, the rates of the primary efficacy endpoint were similar between the groups (55 [14·8%] in the Portico group vs 48 [13·4%] in the commercial valve group; difference 1·5%, 95% CI -3·6 to 6·5 [UCB 5·7%]; pnon-inferiority=0·0058, psuperiority=0·50). At 2 years, rates of death (80 [22·3%] vs 70 [20·2%]; p=0·40) or disabling stroke (10 [3·1%] vs 16 [5·0%]; p=0·23) were similar between groups. INTERPRETATION: The Portico valve was associated with similar rates of death or disabling stroke at 2 years compared with commercial valves, but was associated with higher rates of the primary composite safety endpoint including death at 30 days. The first-generation Portico valve and delivery system did not offer advantages over other commercially available valves. FUNDING: Abbott.
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Estenose da Valva Aórtica/cirurgia , Próteses Valvulares Cardíacas , Mortalidade , Complicações Pós-Operatórias/epidemiologia , Desenho de Prótese , Acidente Vascular Cerebral/epidemiologia , Substituição da Valva Aórtica Transcateter , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Austrália , Transfusão de Sangue , Causas de Morte , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/terapia , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/terapia , Diálise Renal , Índice de Gravidade de Doença , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Data regarding efficacy of various stent and embolic protection device (EPD) combinations to prevent stroke during carotid artery stenting (CAS) is limited. We compared post-procedure inpatient neurologic outcomes across various carotid stent-EPD platforms recorded in the Vascular Quality Initiative (VQI) registry. METHODS: We analyzed 13,786 consecutive CAS procedures in the VQI registry performed between January 1, 2005 and December 31, 2015. The most commonly used stent-EPD combinations (n = 5407) were included in the analysis. Post-procedure inpatient neurologic outcomes included (1) ipsilateral stroke/transient ischemic attack (TIA) and (2) any stroke/TIA. Multivariate generalized estimating equation regression analysis was performed, adjusting for age, sex, tobacco use, coronary artery disease, congestive heart failure, prior stroke/TIA, hypertension, history of carotid revascularization, and presence of a second ipsilateral stenosis >70%, to determine whether risk of outcomes differed according to device. RESULTS: Of 13,786 CAS procedures, Xact-Emboshield (n = 2,438, 17.6%), Precise-Angioguard (n = 1,480, 10.7%), Acculink-Accunet (n = 829, 6.01%), and Acculink-Emboshield (n = 660, 4.8%) were the most commonly used combinations, accounting for a total of 5,407 procedures. Inpatient event rates for ipsilateral stroke/TIA and any stroke/TIA were 1.9 and 2.7% in the Accunet-Acculink, 3.0 and 3.2% in Acculink-Emboshield, 3.2 and 4.1% in Precise-Angioguard and 2.2 and 3.0% in Xact-Emboshield. There was no evidence of difference in risk of ipsilateral stroke/TIA or any stroke/TIA across device combinations (P = 0.15 and P = 0.16, respectively). CONCLUSION: CAS with current carotid stent-EPD combinations is associated with low rates of inpatient stroke/TIA. There is no statistically significant difference in rates of inpatient stroke/TIA across device combinations.
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Estenose das Carótidas/terapia , Dispositivos de Proteção Embólica , Procedimentos Endovasculares/instrumentação , Stents , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/prevenção & controle , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: High-risk percutaneous coronary intervention (PCI) supported by percutaneous left ventricular assist devices offers a treatment option for patients with severe symptoms, complex and extensive coronary artery disease, and multiple comorbidities. The extrapolation from clinical trial to real-world practice has inherent uncertainties. We compared the characteristics, procedures, and outcomes of high-risk PCI supported by a microaxial pump (Impella 2.5) in a multicenter registry versus the randomized PROTECT II trial (NCT00562016). METHODS: The USpella registry is an observational multicenter voluntary registry of Impella technology. A total of 637 patients treated between June 2007 and September 2013 were included. Of them, 339 patients would have met enrollment criteria for the PROTECT II trial. These were compared with 216 patients treated in the Impella arm of PROTECT II. RESULTS: Compared to the clinical trial, registry patients were older (70 ± 11.5 vs 67.5 ± 11.0 years); more likely to have chronic kidney disease (30% vs 22.7%), prior myocardial infarction (69.3% vs 56.5%), or prior bypass surgery (39.4% vs. 30.2%); and had similar prevalence of diabetes, peripheral vascular disease, and prior stroke. Registry patients had more extensive coronary artery disease (2.2 vs 1.8 diseased vessels) and had a similar Society of Thoracic Surgeons predicted risk of mortality. At hospital discharge, registry patients experienced a similar reduction in New York Heart Association class III to IV symptoms compared to trial patients. Registry patients had a trend toward lower in-hospital mortality (2.7% vs 4.6, P = .27). CONCLUSIONS: USpella provides a real-world and contemporary estimation of the type of procedures and outcomes of high-risk patients undergoing PCI supported by Impella 2.5. Despite the higher risk of registry patients, clinical outcomes appeared to be favorable and consistent compared with the randomized trial.
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Doença da Artéria Coronariana/terapia , Coração Auxiliar , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Idoso , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Masculino , Estudos Prospectivos , Volume Sistólico , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
BACKGROUND: In the setting of ST-segment elevation myocardial infarction, timely restoration of normal blood flow is associated with improved myocardial salvage and survival. Despite improvements in door-to-needle and door-to-balloon times, there remains an unmet need with respect to improved symptom-to-door times. A prior report of an implanted device to monitor ST-segment deviation demonstrated very short times to reperfusion among patients with an acute coronary syndrome (ACS) with documented thrombotic occlusion. The goal of the ANALYZE ST study is to evaluate the safety and effectiveness of a novel ST-segment monitoring feature using an existing implantable cardioverter-defibrillator (ICD) among patients with known coronary artery disease. METHODS: The ANALYZE ST study is a prospective, nonrandomized, multicenter, pivotal Investigational Device Exemption study enrolling 5,228 patients with newly implanted ICD systems for standard clinical indications who also have a documented history of coronary artery disease. Patients will be monitored for 48 months, during which effectiveness of the device for the purpose of early detection of cardiac injury will be evaluated by analyzing the sensitivity of the ST monitoring feature to identify clinical ACS events. In addition, the safety of the ST monitoring feature will be evaluated through the assessment of the percentage of patients for which monitoring produces a false-positive event over the course of 12 months. CONCLUSIONS: The ANALYZE ST trial is testing the hypothesis that the ST monitoring feature in the Fortify ST ICD system (St. Jude Medical, Inc., St. Paul, MN) (or other ICD systems with the ST monitoring feature) will accurately identify patients with clinical ACS events.
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Síndrome Coronariana Aguda/diagnóstico , Arritmias Cardíacas/terapia , Desfibriladores Implantáveis , Eletrocardiografia , Monitorização Fisiológica/métodos , Síndrome Coronariana Aguda/etiologia , Arritmias Cardíacas/complicações , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Fatores de TempoRESUMO
OBJECTIVE: To compare the use of regadenoson to adenosine for measurement of fractional flow reserve (FFR). BACKGROUND: FFR is an accepted method to assess the functional significance of intermediate coronary artery stenoses and uses adenosine to induce maximal hyperemia. The use of the selective A2a receptor agonist regadenoson for FFR is not established. METHODS: Fifty-seven patients undergoing clinically indicated FFR assessment of intermediate coronary stenoses were included. For the initial assessment of FFR, hyperemia was achieved by a standard intravenous adenosine infusion (140 mcg/kg/min). After a washout period of 10 min, FFR was reassessed using regadenoson as a single 0.4 mg intravenous bolus. FFR measurements were recorded at baseline and following maximal hyperemia with both agents. RESULTS: Mean age was 57 ± 8 years and 47 were male. Sixty coronary lesions were evaluated and were located in the left anterior descending in 34, the left circumflex in 9, right coronary in 15, and left main coronary artery in 2. Mean ( ± SD) FFR following adenosine and regadenoson was 0.79 ( ± 0.09) and 0.79 (±0.09), respectively, P = NS. Time to FFR nadir was shorter with regadenoson compared to adenosine, 36.6 ± 24 versus 66 ± 0.19 sec, P < 0.0001, respectively. No patients experienced any significant side effects related to regadenoson. CONCLUSIONS: Regadenoson is a viable alternative to intravenous adenosine for achieving maximal hyperemia during FFR assessment. Compared to adenosine, regadenoson has a similar hemodynamic response, achieves more rapid hyperemia, is easier to use, and has an excellent side-effect profile.
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Agonistas do Receptor A2 de Adenosina , Adenosina , Cateterismo Cardíaco , Estenose Coronária/diagnóstico , Reserva Fracionada de Fluxo Miocárdico , Purinas , Pirazóis , Vasodilatadores , Adenosina/administração & dosagem , Adenosina/efeitos adversos , Agonistas do Receptor A2 de Adenosina/administração & dosagem , Agonistas do Receptor A2 de Adenosina/efeitos adversos , Idoso , Angiografia Coronária , Estenose Coronária/fisiopatologia , Feminino , Hemodinâmica , Humanos , Hiperemia/fisiopatologia , Infusões Intravenosas , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Purinas/administração & dosagem , Purinas/efeitos adversos , Pirazóis/administração & dosagem , Pirazóis/efeitos adversos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Vasodilatadores/administração & dosagem , Vasodilatadores/efeitos adversosRESUMO
Objective.Instantaneous, non-invasive evaluation of left ventricular end-diastolic pressure (LVEDP) would have significant value in the diagnosis and treatment of heart failure. A new approach called cardiac triangle mapping (CTM) has been recently proposed, which can provide a non-invasive estimate of LVEDP. We hypothesized that a hybrid machine-learning (ML) method based on CTM can instantaneously identify an elevated LVEDP using simultaneously measured femoral pressure waveform and electrocardiogram (ECG).Approach.We studied 46 patients (Age: 39-90 (66.4 ± 9.9), BMI: 20.2-36.8 (27.6 ± 4.1), 12 females) scheduled for clinical left heart catheterizations or coronary angiograms at University of Southern California Keck Medical Center. Exclusion criteria included severe mitral/aortic valve disease; severe carotid stenosis; aortic abnormalities; ventricular paced rhythm; left bundle branch and anterior fascicular blocks; interventricular conduction delay; and atrial fibrillation. Invasive LVEDP and pressure waveforms at the iliac bifurcation were measured using transducer-tipped Millar catheters with simultaneous ECG. LVEDP range was 9.3-40.5 mmHg. LVEDP = 18 mmHg was used as cutoff. Random forest (RF) classifiers were trained using data from 36 patients and blindly tested on 10 patients.Main results.Our proposed ML classifier models accurately predict true LVEDP classes using appropriate physics-based features, where the most accurate demonstrates 100.0% (elevated) and 80.0% (normal) success in predicting true LVEDP classes on blind data.Significance.We demonstrated that physics-based ML models can instantaneously classify LVEDP using information from femoral waveforms and ECGs. Although an invasive validation, the required ML inputs can be potentially obtained non-invasively.
Assuntos
Eletrocardiografia , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Adulto , Idoso de 80 Anos ou mais , Artéria Femoral/fisiopatologia , Pressão Sanguínea/fisiologia , Aprendizado de Máquina , Processamento de Sinais Assistido por Computador , Diástole , Função Ventricular EsquerdaRESUMO
Aims: Myocardial infarction (MI) is one of the leading causes of death worldwide. It is well accepted that early diagnosis followed by early reperfusion therapy significantly increases the MI survival. Diagnosis of acute MI is traditionally based on the presence of chest pain and electrocardiogram (ECG) criteria. However, around 50% of the MIs are without chest pain, and ECG is neither completely specific nor definitive. Therefore, there is an unmet need for methods that allow detection of acute MI or ischaemia without using ECG. Our hypothesis is that a hybrid physics-based machine learning (ML) method can detect the occurrence of acute MI or ischaemia from a single carotid pressure waveform. Methods and results: We used a standard occlusion/reperfusion rat model. Physics-based ML classifiers were developed using intrinsic frequency parameters extracted from carotid pressure waveforms. ML models were trained, validated, and generalized using data from 32 rats. The final ML models were tested on an external stratified blind dataset from additional 13 rats. When tested on blind data, the best ML model showed specificity = 0.92 and sensitivity = 0.92 for detecting acute MI. The best model's specificity and sensitivity for ischaemia detection were 0.85 and 0.92, respectively. Conclusion: We demonstrated that a hybrid physics-based ML approach can detect the occurrence of acute MI and ischaemia from carotid pressure waveform in rats. Since carotid pressure waveforms can be measured non-invasively, this proof-of-concept pre-clinical study can potentially be expanded in future studies for non-invasive detection of MI or myocardial ischaemia.
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OBJECTIVE: To test the hypothesis that in patients with peripheral arterial disease (PAD) and claudication, treated with maximal tolerated statin therapy, the addition of a monthly subcutaneous injection of evolocumab for 6 months improves treadmill walking performance. BACKGROUND: Lipid lowering therapy improves walking parameters in patients with PAD and claudication. Evolocumab decreases cardiac and limb adverse events in patients with PAD; however, the effect of evolocumab on walking performance is not known. METHODS: We performed a double-blind, randomized, placebo-controlled study to compare maximal walking time (MWT) and pain free walking time (PFWT) in patients with PAD and claudication treated with monthly subcutaneous injections of evolocumab 420 mg (n = 35) or placebo (n = 35). We also performed measurements of lower limb perfusion, brachial flow mediated dilatation (FMD), carotid intima media thickness (IMT), and serum biomarkers of PAD disease severity. RESULTS: After six-months of treatment with evolocumab MWT increased by 37.7 % (87.5 ± 24 s) compared to 1.4 % (-21.7 ± 22.9 s) in the placebo group, p = 0.01. PFWT increased by 55.3 % (67.3 ± 21.2 s) in the evolocumab group compared to 20.3 % (8.5 ± 20.3 s) in the placebo group, p = 0.051. There was no difference in lower extremity arterial perfusion measurements. FMD increased by 42.0 ± 73.9 % (1.01 ± 0.7 %) in the evolocumab group and decreased by 16.29 ± 20.06 % (0.99 ± 0.68 %) in the placebo group (p < 0.001). IMT decreased by 7.16 ± 4.6 % (0.06 ± 0.04 mm) in the evolocumab group and increased by 6.68 ± 4.9 % (0.05 ± 0.03 mm) in the placebo group, (p < 0.001). CONCLUSIONS: The addition of evolocumab to maximal tolerated statin therapy improves maximal walking time in patients with PAD and claudication, increases FMD, and decreases IMT. CONDENSED ABSTRACT: Peripheral arterial disease (PAD) impairs quality of life by causing lower extremity intermittent claudication, rest pain, or amputation. Evolocumab is a monthly injectable monoclonal antibody medication that reduces cholesterol. In this study, we randomly treated patients with PAD and claudication, and on background statin therapy, with evolocumab or placebo, and found that evolocumab improves walking performance on a treadmill test by increasing maximal walking time. We also found that evolocumab decreases plasma MRP-14 levels, a marker of PAD severity.
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Inibidores de Hidroximetilglutaril-CoA Redutases , Doença Arterial Periférica , Humanos , Espessura Intima-Media Carotídea , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/tratamento farmacológico , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/tratamento farmacológico , Qualidade de Vida , Caminhada , Método Duplo-CegoRESUMO
Orthotopic liver transplantation (OLT) is a viable treatment option for end-stage liver disease. Significant perioperative stress is placed on the cardiovascular system because of hemodynamic changes and the length of the operation. Diagnosis and treatment of cardiovascular disease before OLT are imperative to ensure favorable outcomes. Considerable variability exists among practitioners caring for these patients. Institutions tailor their protocols on the basis of local and historical practices, the preferences of the cardiologists, and the OLT team, and algorithms are not often revised or updated on the basis of the available evidence. In collaboration with cardiology and hepatology experts from leading OLT centers, we sought to examine the diagnostic cardiovascular workup of OLT candidates, including a review of the available literature on the diagnostic modalities used to screen cardiovascular disease before OLT. We advocate an emphasis on noninvasive methods to assess cardiovascular risk with reserved use of invasive risk stratification in select patients.
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Chronic total occlusions occur in approximately 40% of patients with peripheral vascular disease and are a difficult lesion subset to treat by endovascular approaches. The challenge lies in the difficulty in placing a wire across the site of occlusion and remaining in an intraluminal position. Conventional percutaneous transluminal balloon angioplasty for chronic total occlusions involves advancing a stiff wire through the site of obstruction, has the chance for vessel dissection and perforation, and is associated with high rates of procedural failure. Several mechanical devices have thus been developed to treat peripheral chronic total occlusions. In this article, we provide a review of the currently available devices that may increase the procedural success of treating peripheral chronic total occlusions.
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Arteriopatias Oclusivas/terapia , Dispositivos de Acesso Vascular , Angioplastia a Laser , Arteriopatias Oclusivas/complicações , Doença Crônica , HumanosRESUMO
Coronary artery aneurysm (CAA) is an uncommon and often incidental finding on coronary angiography but can present with symptoms related to myocardial ischemia. The most common etiology is atherosclerosis, accounting for over 50% of cases, but CAAs can also be congenital or secondary to percutaneous coronary artery revascularization procedures, inflammatory arterial diseases, connective tissue disorders, and perhaps drug-eluting-stent (DES) implantation. A current lack of uniform guidelines for their therapeutic management, especially in the setting of DES, leaves their optimum treatment somewhat controversial. Polytetrafluoroethylene-covered stents have gained popularity in recent years for percutaneous treatment of CAAs; however, their failure to endothelialize is associated with increased risk of thromboocclusive events. We describe two symptomatic patients presenting with large CAAs, one forming after DES implantation, that we treated using the double-stent method, in which one stent is placed within another. The intent is to reduce stent permeability across the aneurysm and promote blood stasis within it, thereby encouraging aneurysm thrombosis and meanwhile preserving the stents' ability to endothelialize. The immediate angiographic result revealed markedly reduced filling of the aneurysms and aneurysm thrombosis was later confirmed at follow-up. Both patients have remained asymptomatic during at least 9 months of follow-up. To the best of our knowledge, this is the first case report describing the use of the double-stent method as an alternative to treat CAAs percutaneously.
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Angioplastia Coronária com Balão/instrumentação , Aneurisma Coronário/cirurgia , Stents , Adulto , Aneurisma Coronário/diagnóstico , Angiografia Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Permeabilidade , Inibidores da Agregação Plaquetária/uso terapêutico , Desenho de Prótese , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
BACKGROUND: Aortic stenosis (AS) is the most common cause for valve replacement in the United States. The pathophysiology of AS involves obstruction to the left ventricular (LV) outflow and reduced arterial compliance. The intrinsic frequency (IF) method is a system-based approach for hemodynamic monitoring of the LV-arterial system and involves determination of ω1 and ω2, which represent the dynamics of LV systolic and vascular function, respectively. Total frequency variation of the systemic circulation is the difference between these IFs (Δω = ω1- ω2). OBJECTIVE: Our goal in this study was to investigate whether Δω, obtained from the ascending aortic pressure waveform, can be indicative of LV-arterial coupling after transcatheter aortic valve replacement (TAVR). APPROACH: Thirty patients undergoing elective TAVR for severe, symptomatic AS were included. We applied the IF method to assess the immediate effects of TAVR on LV-arterial coupling. MAIN RESULTS: Mean age was 86 ± 4 years, 50% were male with a mean aortic valve area of 0.7 cm2 and mean ejection fraction (EF) of 59 ± 7%. The results showed a significant decrease in Δω (47.6 to 9.5 bpm, p < 0.00001) and a significant increase in ω2 (51.9 to 84.6 bpm, p < 0.00001) immediately post TAVR. SIGNIFICANCE: These preliminary findings indicate that the IF method can be used to evaluate improvements in LV hemodynamics immediately following TAVR. Use of the IF method may have implications for patients undergoing TAVR with impaired LV systolic function.
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Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Feminino , Humanos , Masculino , Índice de Gravidade de Doença , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
BACKGROUND: Drug eluting stents (DES) are used in the majority of patients undergoing percutaneous coronary intervention (PCI). Factors associated with the use of bare metal stents (BMS) for patients undergoing primary PCI for ST elevation myocardial infarction (STEMI) have not been adequately explored. The objective of this study was to evaluate factors associated with BMS use in STEMI patients undergoing primary PCI. METHODS: Patients undergoing primary PCI for STEMI between January 2008 and February 2015 were retrospectively identified. Patients who received both a DES and BMS were included in the DES group and patients receiving balloon angioplasty only were excluded. Baseline demographics, angiographic variables, procedure related variables and in-hospital events were collected. Multivariate analysis was performed to identify factors associated with BMS use. RESULTS: Eight hundred and sixty-five patients underwent primary PCI for STEMI during the study period. Seventy-two patients (8.3%) received balloon angioplasty only and were excluded, yielding 793 patients for the study cohort. Three hundred fifty-two patients (44%) received BMS and 441 patients (56%) received DES. Patients receiving DES had a higher prevalence of diabetes mellitus, prior myocardial infarction, prior PCI, left anterior descending artery culprit location and Medicaid Insurance compared to those receiving BMS. Patients receiving BMS had a higher prevalence of cardiogenic shock and right coronary artery culprit location. Unadjusted in-hospital mortality was significantly higher for patients receiving BMS compared to patients receiving DES, 11.1% vs 3.2%, respectively, p < 0.0001. Multivariate predictors of BMS use were cardiogenic shock (OR 30.3; 95% CI 11.25 to 81.73) and diabetes mellitus (OR 2.99; 95% CI 1.04 to 8.64). CONCLUSION: In a contemporary series of patients undergoing primary PCI for STEMI, BMS were used in 44% of patients and independent factors associated with BMS use were cardiogenic shock and diabetes mellitus.
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Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Stents Farmacológicos , Humanos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Severe coronary artery calcification is a challenge for percutaneous coronary intervention (PCI), particularly in left main coronary artery disease (LM-CAD). Rotational atherectomy (RA) is a useful tool for modification of calcified plaque prior to PCI. We report our experience with RA for severely calcified LM-CAD. METHODS: From January 2008 to January 2017, all patients who underwent RA-assisted LM-PCI were evaluated. The study population included both protected and unprotected LM-CAD patients. Clinical characteristics and in-hospital outcomes were collected retrospectively. In-hospital outcomes included post-PCI myocardial infarction, stroke, death, emergency coronary artery bypass graft surgery, and urgent repeat PCI. Angiographic success was defined by residual stenosis <20% and presence of TIMI 3 flow. RESULTS: Fifty-five consecutive patients who underwent RA-assisted PCI of LM-CAD were identified (mean age, 73.0 ± 10 years; 64% male). Mean left ventricular ejection fraction was 37.5 ± 15.7%. Fifty-one patients (93%) had multivessel disease and 39 patients (71%) underwent RA-assisted LM-PCI with use of a mechanical support device. The median largest burr size used was 1.5 mm. The mean number of LM stents implanted was 0.95 ± 0.3. The mean LM stent diameter and length were 3.7 ± 0.3 mm and 15.8 ± 7.5 mm, respectively. Intravascular ultrasound was used to assess vessel size and stent apposition in 20 patients (36.0%). Angiographic success was obtained in all patients (100%). CONCLUSION: Despite technical challenges, RA of the LM coronary artery can be performed safely and is associated with a high rate of angiographic success.
Assuntos
Aterectomia Coronária , Doença da Artéria Coronariana , Vasos Coronários , Pacientes Internados/estatística & dados numéricos , Intervenção Coronária Percutânea , Calcificação Vascular , Idoso , Idoso de 80 Anos ou mais , Aterectomia Coronária/efeitos adversos , Aterectomia Coronária/métodos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/metabolismo , Doença da Artéria Coronariana/patologia , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Vasos Coronários/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Risco Ajustado , Índice de Gravidade de Doença , Estados UnidosRESUMO
BACKGROUND: Patients with massive and submassive pulmonary embolism (PE) require rapid identification, triage, and consideration for reperfusion therapy. Use of an existing ST-segment elevation myocardial infarction (STEMI) team and activation protocol may be an effective means to care for these patients. OBJECTIVE: The objective of this analysis was to evaluate a pilot study using the STEMI team and a dedicated PE protocol for treatment of patients with massive and submassive PE. METHODS: From June 2014 to April 2016, a total of 40 patients with massive and submassive PE were evaluated. Baseline demographics, mode of hospital entry (transfer-in, in-hospital, and emergency department [ED] arrival), treatment time intervals (door to computed tomography PE protocol [CTPE], CTPE to invasive pulmonary angiogram, door to treatment time), procedures performed, and in-hospital clinical events were collected. RESULTS: Mean age was 56 ± 14 years, 17 (42%) were male, and 12 (30%) had a prior history of deep venous thrombosis or PE. Twenty-three patients (57%) had massive PE and 17 patients (43%) had submassive PE. Mode of hospital entry was transfer-in (38%), in-hospital (20%), and ED arrival (42%). Four patients (10%) presented with cardiac arrest, 8 patients (20%) required intubation, and 5 patients (12%) required extracorporeal membrane oxygenation. Ten patients (25%) received anticoagulation therapy or placement of inferior vena cava filter, 3 patients (7.5%) received diagnostic pulmonary angiography alone, and 27 patients (67.5%) received endovascular treatment. For patients arriving via the ED, door to CTPE was 4.9 ± 3.6 hours, CTPE to diagnostic pulmonary angiography was 7.8 ± 8.5 hours, and door to treatment time was 10.2 ± 9.0 hours. Endovascular devices utilized included combinations of rheolytic and other thrombectomy devices as well as catheter-directed fibrinolysis. Length of hospital stay was 15 ± 15 days and in-hospital survival rate was 90%. CONCLUSIONS: Use of an existing STEMI team and activation protocol is a feasible method to care for patients with massive and submassive PE. This pilot study demonstrated rapid treatment times with low in-hospital mortality.
Assuntos
Cardiologistas , Equipe de Assistência ao Paciente , Embolia Pulmonar/terapia , Trombectomia/métodos , Serviço Hospitalar de Emergência , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST , Terapia Trombolítica/métodosRESUMO
BACKGROUND: Mitral regurgitation (MR) is a common valvular disorder, occurring in up to 10% of the general population. Although surgery is the established treatment for primary MR, many patients do not receive appropriate therapy. The objective of this study was to determine the incidence and treatment pattern of patients with severe MR evaluated at a tertiary medical center and determine factors associated with receiving surgery. METHODS: All patients with moderate-severe and severe MR undergoing transthoracic echocardiography from 2011 to 2016 were identified. Patients with prior mitral valve surgery were excluded. Treatment recommendations were classified as referral to cardiology, referral to cardiothoracic surgery (CTS), receiving mitral valve surgery or receiving MitraClip. A multivariate logistic regression model was used to evaluate factors associated with referral to CTS or receiving surgery. RESULTS: During the study period, 1918 transthoracic echocardiogram were performed and 412 patients with moderate-severe or severe MR were identified. One hundred sixty-six patients (40%) had primary MR and 246 patients (60%) had secondary MR. For those with primary MR, 75 patients (45%) received treatment (surgery, nâ¯=â¯60 and MitraClip, nâ¯=â¯15) and 91 patients (55%) did not receive treatment. One hundred patients (60%) were referred to CTS and 128 patients (77%) were referred to cardiology. Patients undergoing surgery were younger (62.6⯱â¯14.2â¯years vs 72.0⯱â¯14â¯years, pâ¯<â¯0.001), with a higher prevalence of heart failure (57% vs 40%, pâ¯=â¯0.044) and a lower prevalence of stroke (3% vs 24%, pâ¯<â¯0.001) and hypertension (54% vs 74%, pâ¯=â¯0.012), compared to patients not undergoing surgery, respectively. Ejection fraction (60.4⯱â¯10.9% vs 56.3⯱â¯11.6%, pâ¯=â¯0.034), left ventricular end diastolic diameter (53.2⯱â¯10.3â¯mm vs 48.7⯱â¯10.9â¯mm, pâ¯=â¯0.040) and effective regurgitant orifice area (0.5⯱â¯0.4â¯cm2 vs 0.3⯱â¯0.1â¯cm2) were higher in patients undergoing surgery, compared to patients not undergoing surgery, respectively. The most common reason for not receiving surgery was that MR was not addressed by the treating physician and lost to clinical follow-up. Over 50% of patients that did not receive surgery had at least 1 indication based upon current practice guidelines. CONCLUSIONS: In contemporary clinical practice, less than half of patients with moderate-severe and severe primary MR received surgery and many were not referred for surgical consultation.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Insuficiência da Valva Mitral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/cirurgia , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: To investigate platelet reactivity in patients with critical limb ischemia (CLI) after switching from clopidogrel to ticagrelor. BACKGROUND: High on-treatment platelet reactivity (HPR) is highly prevalent in patients with CLI treated with clopidogrel. The effect of ticagrelor in patients with CLI is not known, however. METHODS: We performed P2Y12 platelet receptor inhibition studies (VASP and VerifyNow) in 50 patients with CLI. Tests were performed before and 6±1h after daily 75mg clopidogrel dose. Patients were then switched to ticagrelor 90mg twice daily for two weeks and platelet assays repeated. Patients were divided based on VerifyNow P2Y12 reaction units (PRU). Group 1: HPR defined as PRU ≥208 and Group 2: Appropriate platelet inhibition (API), PRU <208. RESULTS: After two weeks of uninterrupted antiplatelet therapy, mean PRU results were 173 PRU and 71 PRU at baseline (p<0.0001) and 140 PRU and 63 PRU after 6h (p<0.0001) for clopidogrel and ticagrelor, respectively. Before daily clopidogrel dose, 36% of patients (n=18) demonstrated HPR and after 6h, 30% (n=15). One patient (2%) had HPR on ticagrelor. Ninety-four percent of patients with HPR on clopidogrel demonstrated appropriate platelet inhibition after switching to ticagrelor and all patients with API on clopidogrel remained with API after switching to ticagrelor. Six hours after daily dosing, VASP-PRI >50% was found in 42% of clopidogrel and 2% of ticagrelor treated patients. CONCLUSIONS: Among patients with CLI, ticagrelor achieved greater platelet inhibition than clopidogrel during maintenance treatment and at 6h after daily dosing. High on-treatment platelet reactivity to clopidogrel in patients with CLI can be overcome by switching to ticagrelor.
Assuntos
Plaquetas/efeitos dos fármacos , Substituição de Medicamentos , Isquemia/tratamento farmacológico , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação Plaquetária/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Ticagrelor/administração & dosagem , Idoso , Plaquetas/metabolismo , Clopidogrel/administração & dosagem , Estado Terminal , Substituição de Medicamentos/efeitos adversos , Feminino , Humanos , Isquemia/sangue , Isquemia/diagnóstico , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Agregação Plaquetária/efeitos dos fármacos , Inibidores da Agregação Plaquetária/efeitos adversos , Testes de Função Plaquetária , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Receptores Purinérgicos P2Y12/sangue , Receptores Purinérgicos P2Y12/efeitos dos fármacos , Ticagrelor/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: The goal of this study is to establish the prevalence of high on-treatment platelet reactivity to aspirin (HPRA) and clopidogrel (HPRC) in patients with critical limb ischemia (CLI). BACKGROUND: CLI is associated with an increased risk of death and cardiovascular events. Unlike other patient populations with atherosclerotic cardiovascular disease, previous studies failed to demonstrate a benefit of antiplatelet therapy in patients with CLI. METHODS: From June 2014 to November 2016, we performed platelet reactivity studies for P2Y12 and thromboxane A2 (TXA2) inhibition in 100 CLI patients receiving daily treatment with aspirin and clopidogrel. P2Y12 inhibition was measured by two assays: vasodilator-stimulated phosphoprotein (VASP) and VerifyNow P2Y12 assays. HPRC was defined as VerifyNow P2Y12 reactive units (PRU) >208 and VASP-platelet reactivity index (VASP-PRI) >50%. TXA2 inhibition was measured with the VerifyNow aspirin test and HPRA was defined as aspirin reaction units (ARU) >550. RESULTS: Mean age was 67±11 years, 50% were male, 80% had diabetes mellitus, and 26% had chronic renal insufficiency. Thirty-three percent of patients had a PRU >208 and 46% a VASP-PRI >50%. HPRC was present in 26% of patients based on the criteria of both a PRU >208 and VASP-PRI >50%. HPRA was present in 25% of patients. The overall prevalence of HPR to ASA or clopidogrel was 35% and HPR to both drugs was present in 8% of patients. Clinical characteristics were similar between groups. CONCLUSIONS: HPR to aspirin or clopidogrel is highly prevalent in patients with CLI. Nearly one in ten patients with CLI is a hyporesponder to both aspirin and clopidogrel.
Assuntos
Aspirina/uso terapêutico , Plaquetas/efeitos dos fármacos , Clopidogrel/uso terapêutico , Isquemia/tratamento farmacológico , Doença Arterial Periférica/tratamento farmacológico , Ativação Plaquetária/efeitos dos fármacos , Inibidores da Agregação Plaquetária/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Plaquetas/metabolismo , Moléculas de Adesão Celular/sangue , Clopidogrel/efeitos adversos , Estado Terminal , Quimioterapia Combinada , Feminino , Humanos , Isquemia/sangue , Isquemia/diagnóstico , Masculino , Proteínas dos Microfilamentos/sangue , Pessoa de Meia-Idade , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Fosfoproteínas/sangue , Inibidores da Agregação Plaquetária/efeitos adversos , Testes de Função Plaquetária , Estudos Prospectivos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Receptores Purinérgicos P2Y12/sangue , Receptores Purinérgicos P2Y12/efeitos dos fármacos , Tromboxano A2/sangue , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The optimal stent for use in saphenous vein graft (SVG) intervention is still debatable. Multiple randomized trials have compared drug-eluting stents (DES) to bare metal stents (BMS) in SVG interventions with conflicting results. METHODS: Authors searched the online databases for randomized controlled trials (RCTs) comparing DES to BMS in SVG percutaneous coronary interventions (PCI). We performed a meta-analysis using a random effects model to calculate the odds ratio for outcomes of interest. RESULTS: Authors studied six RCTs that included 1592 patients undergoing PCI of SVG. The mean follow up was 42â¯months. Patients mean age was the same in both groups: 70.3â¯years in the DES group (approximately 93.3% male) and 70.3â¯years in the BMS group (approximately 93.8% male). Vein graft age was 13.4â¯years in the DES PCI arm vs. 13.4â¯years in the BMS PCI arm. Four of the six trials reported data on embolic protection device use: 67% (303/452) in the DES arm vs. 67.9% (309/455) in the BMS arm. The primary outcome of long-term all-cause mortality was not different between DES vs. BMS (15.2% vs. 14.1%, OR 1.12, 95% CI 0.67-1.88; Pâ¯=â¯0.66). Secondary outcomes were also similar between DES and BMS: major adverse cardiovascular events (31.6% vs. 33.1%, OR 0.79, 95% CI 0.45-1.38; Pâ¯=â¯0.41); cardiac death (9% vs. 8.6%, OR 1.12, 95% CI 0.55-2.30; Pâ¯=â¯0.75); myocardial infarction (8% vs. 9.5%, OR 0.84, 95% CI 0.47-1.51; Pâ¯=â¯0.57); target lesion revascularization (16.4% vs. 14.4%, OR 0.98, 95% CI 0.50-1.92; Pâ¯=â¯0.95); and target vessel revascularization (19% vs. 19.4%, OR 0.75, 95% CI 0.41-1.34; Pâ¯=â¯0.33). CONCLUSION: At a mean follow-up of 42â¯months, no difference was observed in clinical outcomes between DES and BMS in SVG interventions.