Revista Brasileira de Cardiologia Invasiva最新文献

Background

Historically, patients with prior coronary artery bypass graft (CABG) surgery undergoing primary percutaneous coronary intervention (PCI) have a worse prognosis than patients without prior CABG. However, more contemporary analyses have contested these findings. This study's aim was to evaluate the 30‐day clinical outcomes in patients with and without prior CABG submitted to primary PCI.

Methods

Prospective cohort study, extracted from the database of Instituto de Cardiologia do Rio Grande do Sul, containing 1,854 patients undergoing primary PCI.

Results

Patients with prior CABG (3.8%) showed, in general, a more severe clinical profile. The time of symptom onset until arrival at the hospital was shorter in this group (2.50 hours [1.46 to 3.66] vs. 3.99 hour [1.99 to 6.50]; p < 0.001), while the door‐to‐balloon time was similar (1.33 hour [0.85 to 2.07] vs. 1.16 hour [0.88 to 1.58]; p = 0.12). Femoral access was more often used in the group with prior CABG (91.5% vs. 62.5%; p < 0.001). Manual thrombus aspiration was less often performed in this group (16.9% vs. 31.1%; p = 0.007), but there was no difference regarding the use of glycoprotein IIb/IIIa inhibitors (28.2% vs. 32.4%, p = 0.28). Angiographic success was lower in the group with prior CABG (80.3% vs. 93.3%; p = 0.009). At 30 days, patients with prior CABG had similar rates of major adverse cardiac events (14.1% vs. 11.2%; p = 0.28), and mortality, although numerically higher, was not statistically significant (13.2% vs. 7.0%, p = 0.07).

Conclusions

In this contemporary analysis, patients with prior CABG undergoing primary PCI had a more severe clinical profile and lower angiographic success, but showed no differences regarding 30‐day clinical outcomes.

Background

The use of statins prior to percutaneous coronary intervention (PCI) has reduced cardiac events in both short and long‐term follow‐up. This study assessed the impact of prior statin use on in‐hospital PCI outcomes in patients with acute coronary syndrome (ACS).

Methods

Retrospective analysis of a multicenter registry of 6,288 consecutive patients undergoing PCI. Of these, 35% had ACS and were evaluated according to statin use (Group 1, n = 1,203) or no use (Group 2, n = 999).

Results

Group 1 showed higher prevalence of dyslipidemia, acute myocardial infarction (AMI), previous coronary artery bypass graft, chronic renal failure, multivessel involvement, bifurcation lesions, and use of drug‐eluting stents. Group 2 showed more primary and rescue PCIs, Killip functional class III/IV, B2/C lesions, thrombi, total occlusions, pre‐procedural TIMI 0/1 flow, presence of collateral circulation, and use of glycoprotein IIb/IIIa inhibitors and aspiration catheters. PCI success was higher in Group 1 (95.1% vs. 92.5%; p = 0.01), and the occurrence of major adverse cerebrovascular and cardiac events (MACCE) (3.7% vs. 5.7%) was more frequent in Group 2. Although the non‐use of statins showed an association with MACCE in the univariate analysis, independent predictors of in‐hospital MACCE were limited to AMI in Killip III/IV and prior coronary artery bypass graft.

Conclusions

ACS patients undergoing PCI who previously used statins had better in‐hospital clinical outcomes; however, statin use was not an independent predictor of MACCE.

Background

Coronary three‐dimensional reconstruction with the combination of intravascular ultrasound and angiography offers advantages over computed tomography angiography of coronary arteries. The authors aimed to present the pilot phase of the validation of a new model of three‐dimensional reconstruction of coronary arteries.

Methods

This study used angiography and intravascular ultrasound examinations already performed by clinical indication in individuals with known or suspected stable coronary artery disease. Image processing, segmentation, and three‐dimensional reconstruction were conducted following specific methodology. For geometrical characterization purposes, tridimensional center lines were obtained.

Results

Three vessels were reconstructed: two left anterior descending arteries and one left circumflex artery. The vessel lumen volume and the overall plaque burden could be easily viewed with three‐dimensional reconstruction. The geometric characterization revealed increased absolute values of length, tortuosity, curvature, and torsion, featuring a greater complexity of the center line of the diseased lumen relative to the center line of the external elastic membrane.

Conclusions

This new methodology, which integrates conventional angiography and intravascular ultrasound, has increased the practicality of the reconstructions, with a gain in volumetric accuracy of the vessel and overall visualization of key aspects of atherosclerotic disease, such as plaque remodeling and distribution.

Background

The increasing use of transcatheter aortic valve implantation (TAVI) in high‐risk patients, especially those with ventricular dysfunction, justifies further evaluation of the selection and the results of the procedure. A database was used to characterize the profile of patients and evaluate TAVI results according to the degree of ventricular dysfunction.

Methods

This was a longitudinal observational study that included all patients with severe aortic stenosis (AoS) submitted to TAVI between 2009 and 2014, comparing those with left ventricular ejection fraction (LVEF) ≤ 40% vs. > 40%. The safety and efficacy outcomes were evaluated at 30 days and 1 year.

Results

Of the 172 patients, 20 (11.6%) had LVEF ≤ 40%. These patients were younger, with a higher prevalence of smoking, previous acute myocardial infarction, coronary artery bypass graft surgery, permanent pacemaker, and pulmonary artery hypertension. Higher functional classes were also more often observed in this group. The group with LVEF ≤ 40% had lower mean aortic valve gradient for an equivalent valve area. The procedure success did not differ between groups. There were no differences in mortality in coronary and cerebrovascular events, bleeding, vascular complications, and acute renal failure in the 30 day and 1 year follow‐up. In the LVEF ≤ 40% group, the mean LVEF increased from 31.5 to 45.1% 1 year after the procedure (p = 0.002).

Conclusions

TAVI in patients with severe AoS and LVEF ≤ 40% does not increase the risk of complications and is associated with LVEF improvement.

Background

The current decline observed in mortality rate among patients with ST‐segment elevation acute myocardial infarction can be attributed not only to the increased use of reperfusion strategies, but also to a change in the demographic profile of this population, notably the reduction in mean age.

Methods

We retrospectively reviewed all patients undergoing primary percutaneous coronary intervention in the period from April 2010 to December 2014. The primary objective was the characterization of the most prevalent risk factors, the angiographic nature of the lesions, the technical aspects of the procedure, and in‐hospital clinical outcomes in patients aged ≤ 45 years, comparing them to those aged > 45 years.

Results

Among 489 patients with acute myocardial infarction, 54 were ≤ 45 years, and 435 were > 45 years. Young patients exhibited a higher prevalence of smoking and obesity, while patients > 45 years were more likely to have hypertension, diabetes mellitus, dyslipidemia, and previous myocardial infarction. Primary percutaneous coronary intervention in young patients was associated with the use of fewer guide catheters, shorter fluoroscopy time, and higher percentage of direct stent implantation. Young patients exhibited good in‐hospital outcomes, with lower rate of adverse cardiac events (3.7% vs. 9.2%; p = 0.30).

Conclusions

Patients aged ≤ 45 years accounted for approximately 10% of cases of ST‐segment elevation acute myocardial infarction and exhibited high prevalence of modifiable risk factors.

Background

In clinical practice, type‐1 (coronary thrombosis) and type‐2 (imbalance between oxygen demand and supply) acute myocardial infarction (AMI) are not clearly differentiated. The aim of this study was to evaluate the prevalence and etiology of type‐2 AMI and compare its profile with that of type‐1 AMI.

Methods

Patients admitted with ST‐segment elevation AMI (STEMI) < 12 hours of symptom onset, and referred for coronary angiography, from 2009 to 2013, were analyzed.

Results

There were 1,960 patients included; 1,817 were analyzed, of whom 1,786 (98.3%) had type‐1 AMI, and 31 (1.7%), type‐2. All patients with type‐2 AMI showed no significant coronary lesions, and 36% of the cases had apical dyskinesia. Type‐2 AMI patients had, in general, a clinical and laboratory profile that was similar to those with type‐1, except for the younger age, lower levels of myocardial necrosis markers, higher probability of having pre‐TIMI 3 flow and higher left ventricular ejection fraction. At 30 days, mortality (3.2 vs. 9.0%; p = 0.23) and the occurrence of death, reinfarction, or need for target‐vessel revascularization (3.2 vs. 13.0%; p = 0.09) were numerically lower in type‐2 AMI.

Conclusions

Few patients with STEMI were classified as type‐2; they had structural abnormalities, isolated or associated with the absence of significant lesions; showed little difference regarding the clinical and laboratory profile, and similar clinical outcomes at 30 days, when compared to patients with type‐1 AMI.

O sistema MitraClip^® foi recentemente aprovado para uso clínico no Brasil para o tratamento percutâneo da insuficiência valvar mitral. Esse dispositivo se baseia na cirurgia de Alfieri, criando um orifício duplo pela união central das duas cúspides da valva mitral. Descrevemos aqui os dois primeiros procedimentos realizados em nosso meio utilizando esse dispositivo. Tratam-se de duas pacientes do sexo feminino, consideradas de alto risco cirúrgico pela idade avançada e pela presença de comorbidades, portadoras de insuficiência mitral degenerativa por prolapso/flail associado à rotura de cordoalhas. Nos dois casos, obteve-se redução expressiva da intensidade da regurgitação mitral com a utilização do MitraClip^®, demonstrando o grande potencial dessa tecnologia inovadora para o tratamento percutâneo da insuficiência valvar mitral.

The MitraClip^TM system has been recently approved for clinical use in Brazil for percutaneous treatment of mitral valve regurgitation. This device is based on the Alfieri surgical procedure, creating a double orifice by bringing together the central segments of the two mitral valve cusps. This report describes the first two procedures performed in Brazil using this device. Two female patients considered to be at high surgical risk due to advanced age and presence of comorbidities were treated, with degenerative mitral regurgitation due to prolapse/flail, associated with chordae tendineae rupture. In both cases, significant mitral regurgitation intensity reduction was obtained using the MitraClip^TM, demonstrating the great potential of this innovative technology for the percutaneous treatment of mitral valve regurgitation.

Background

The Orsiro is a hybrid stent which has passive (amorphous silicon carbide) and active (poly‐L‐lactic acid, PLLA) coatings. The first layer encapsulates the stent struts, promoting lower local inflammation, whereas the second layer releases sirolimus through a biodegradable matrix. This study's aim was to compare the results of percutaneous coronary interventions (PCI) with Orsiro and Xience™ V stents (everolimus‐eluting stent) in daily clinical practice.

Methods

Observational study in which patients were divided into two groups: those who received only one or more Orsiro stents, and those who received only Xience^TM V stents. Early and late outcomes were prospectively collected.

Results

Between September 2012 and March 2014, this study included 92 and 108 patients treated with Orsiro and Xience™ V stents, respectively. Clinical, angiographic, and procedure characteristics were mostly similar between groups. Rates of procedure success (98.9% vs. 95.4%; p = 0.22), in‐hospital mortality (1.1% vs. 0%; p = 0.40) and stent thrombosis (0% vs. 0.9%, p = 0.30) did not differ between groups. Time of follow‐up was 434 ± 111 and 477 ± 66 days (p = 0.23), respectively, and differences in mortality (0.9% vs. 0%, p = 0.30), stent thrombosis (0% vs. 0.9%; p = 0.30), or need for repeat revascularization of the target lesion (0% vs. 0.9%; p = 0.30) were not observed.

Conclusions

Orsiro and Xience™ V stents showed similar performance, with low rates of early and late clinical and angiographic events.