Revista Brasileira de Cardiologia Invasiva最新文献

Background

Intravascular ultrasound (IVUS) is the most widely used ancillary method in Interventional Cardiology, and its analysis depends on standards for acquisition, measurement and interpretation of the images. By associating tissue characterization, the artifact caused by the guidewire may overestimate the percentage of necrotic core in certain lesions, leading to misclassification of fibroatheroma. In this paper we described quantitative and tissue analysis effects resulting from subtracting the effect of guidewire artifact on atherosclerotic lesions in patients with acute coronary syndrome.

Methods

Twenty‐one patients with post‐thrombolysis myocardial infarction were evaluated with grayscale IVUS and iMAPTM technology, totaling 76 lesions.

Results

Grayscale IVUS showed that the lesions had a mean length of 21.01 ± 18.03 mm and revealed high plaque burden (52.07 ± 7.56%). The analysis by iMAPTM demonstrated that, after subtracting the guidewire artifact, there was a reduction of all tissue (necrotic, calcific, lipid and fibrotic) components, but more markedly in necrotic core (mean difference: 3.59%). In addition, after artifact subtraction 12.4% of the lesions that initially exhibited a necrotic core ≥ 10% ceased to be classified as fibroatheroma.

Conclusions

An atheroma analysis by iMAPTM technology showed that the guidewire artifact overestimated the tissue component of the necrotic core. This interference may change, in an erroneous and categorical way, the phenotypic characteristics of more stable and benign (fibrotic) lesions to potentially unstable lesions, for example, fibroatheromas, in a ratio of one out of ten patients.

Left ventricular pseudoaneurysms are usually associated with acute myocardial infarction; however, these conditions may emerge in the late postoperative period of valvar surgery, and this can also occur with aortic pseudoaneurysms. These pseudoaneurysms often affect patients with high surgical risk, and percutaneous treatment is usually performed in reference centers for treatment of congenital heart diseases, due to anatomical characteristics of these defects. We present two cases of left ventricular pseudoaneurysms treated by transapical approach without need for cardiopulmonary bypass, and one case of aortic pseudoaneurysm treated by femoral approach, in which a snare was introduced by contralateral access, to allow for adequate support and guidance of the long sheath for accessing the defect.

Background

The objective of this study was to evaluate the degree of accuracy, precision, correlation, and agreement between the measurements performed by online Quantitative Coronary Angiography (QCA) software with automatic calibration.

Methods

Pilot study that analyzed angiographic images of ten patients through online QCA software using Auto ISO (automatic calibration isocenter) and Auto TOD (Table‐to‐Object Distance) automatic calibration. Catheter size was measured by both methods and the reference diameter was computed. These measurements were compared with the measurement of catheter diameter regarding accuracy, precision, and agreement.

Results

The actual average of the catheter diameter was 1.75 ± 0.32 mm (range 1.33 to 2.67 mm). The measurement of catheters by TOD QCA and ISO QCA resulted in mean diameters of 1.78 ± 0.37 mm and 1.88 ± 0.38 mm, respectively. The accuracy/precision of the TOD QCA and the ISO QCA was 0.03 mm/0.21 mm and 0.12 mm/0.20 mm, respectively. The TOD QCA and ISO QCA measures were among the limits of agreement in 96.3 and 94.7% of cases, respectively, and were significantly correlated (r_s = 0.93, p < 0.01). However, despite the small difference between the methods (0.10 ± 0.10 mm), the ISO QCA measures were significantly higher than those obtained by the TOD QCA (p < 0.01).

Conclusions

Online QCA with automatic calibration has good accuracy, precision, and correlation, which may represent a promising tool in the catheterization laboratory.

Background

The epidemiology of acute myocardial infarction with ST‐segment elevation (STEMI) has been modified in recent years, focusing on young people. Our goal was compare the clinical profile, laboratory, angiographic, and 30‐day clinical outcomes of patients ≤ 40 years with those > 40 years undergoing primary percutaneous coronary intervention (pPCI).

Methods

Prospective cohort study of consecutive patients undergoing pPCI between 2009 and 2011.

Results

A total of 1,055 patients were included, 3.3% of them ≤ 40 years. Young patients were more often black, smokers and with a family history of coronary artery disease, and less often hypertensive and dyslipidemic. In patients ≤ 40 years, leukocyte count and ultrasensitive troponin levels at admission were higher, and high density lipoprotein‐cholesterol, lower. The left anterior descending artery as a culprit vessel and left ventricular ejection fraction did not differ between groups. Although the TIMI 3 flow pre‐intervention was similar, young people showed higher prevalence of myocardial blush 3 pre‐procedure. The door‐to‐balloon time was lower in younger patients (1.0 hour [0.8‐1.4 hour] vs. 1.3 hour [0.9‐1.7 hour]; p = 0.03). At 30 days, patients ≤ 40 years had a mortality of 0% vs. 8.8% for patients > 40 years (p = 0.07).

Conclusions

Patients ≤ 40 years with STEMI and undergoing pPCI show differences in clinical, angiographic and procedural characteristics compared to those > 40 years. In this analysis, representative of the current medical practice, the 30‐day mortality of these patients was very low.

Background

Invasive coronary procedures are common in patients with previous coronary artery bypass graft surgery. Data on the actual role and possible limitations of the radial approach in this subgroup of patients are sparse. The objective of this study was to evaluate the feasibility and safety of radial access in patients surgically revascularized and who underwent subsequent invasive diagnostic or therapeutic coronary procedures, comparing it to the femoral access.

Methods

Between May 2008 and November 2014, 959 procedures were included; 539 performed by radial access and 420 by femoral access. All operators were familiar with both vascular accesses, and the final decision on the route to be used was left to the operators discretion.

Results

The failure rate was 6.1% vs. 0.5% (p < 0.0001), favoring the femoral approach. Major adverse cardiac events (0.4% vs. 0.7%) and vascular complications (1.5% vs. 1.9%) rates were low, with no difference between groups. The choice of the radial approach resulted in greater fluoroscopy time and crossover rate between access routes, especially in diagnostic procedures.

Conclusions

The radial approach was a safe and effective option for invasive coronary procedures in postcoronary artery bypass graft patients, especially for therapeutic procedures.

Background

Pharmacoinvasive therapy (PIT) is feasible in patients with acute myocardial infarction with ST‐segment elevation (STEMI) when timely primary percutaneous coronary intervention (PCI) is unavailable. In this study, we compared women who underwent successful reperfusion PIT with those who required rescue PCI, to identify potential predictors of thrombolytic failure.

Methods

From January 2010 to November 2014, 327 consecutive women with STEMI were referred to a tertiary hospital, 206 after successful thrombolysis (63%) and 121 who required rescue PCI. The groups were compared regarding demographic, clinical and angiographic outcomes, and clinical (TIMI, GRACE, and ZWOLLE CADILLAC) and bleeding (CRUSADE) risk scores. A multivariate logistic regression model was used to identify predictors of thrombolytic failure.

Results

There was no significant difference between the demographic characteristics or the medical history of the groups. Rescue PCI group had significantly higher values of the evaluated scores. Clinical hospital complications and mortality (2.5% vs. 22.0%; p < 0.0001) were more frequent in rescue PCI group. The independent variables associated with rescue PCI were pain‐to‐needle time > 3 h (OR: 3.07, 95%CI: 1.64 to 5.75; p < 0.0001), ZWOLLE score (OR: 1.25; 95%CI: 1.14 to 1.37; p = 0.0001) and creatinine clearance (OR: 1.009, 95%CI: 1.0 to 1.02; p = 0.04).

Conclusions

Women with STEMI who underwent PIT and who required rescue PCI had significantly higher mortality compared to those who achieved initial success of PIT with elective PCI. Pain‐to‐needle time > 3 h, ZWOLLE score and creatinine clearance were independent predictors of the need for rescue PCI.

Background

Despite the better clinical performance of second‐generation drug‐eluting stents (DES) when compared to first‐generation DES in controlled trials, mainly due to reduction in thrombosis rate, it remains unclear whether this benefit extends to diabetic patients treated in the daily practice. We sought to compare the clinical outcomes of unselected diabetic patients treated with either sirolimus eluting stents ‐ SES (first‐generation DES) or everolimus‐eluting stents ‐ EES (second‐generation DES).

Methods

Between January 2007 and October 2014 a total of 798 diabetic patients were treated with SES (n = 414) and EES (n = 384). Long‐term clinical follow‐up was achieved in 99,4% of the population and the groups were compared regarding the occurrence of major adverse cardiac events (MACE) and stent thrombosis.

Results

In both cohorts age was similar, and most patients were male. Stable coronary disease was the most frequent clinical presentation. The number of treated vessels (1.50 ± 0.62 vs. 1.52 ± 0.72; p = 0.88) and the total stent length (36.1 ± 20.4 vs. 37.7 ± 22.2 mm; p = 0.32) were similar between groups. Patients treated with EES showed lower rates of MACE (15% vs. 6.8%, p < 0.001), mainly due to a lower cardiac death (5.3% vs. 1.3%, p < 0.001). There was also less definitive/probable thrombosis with the second generation DES (3.4% vs. 0.5%, p = 0.004).

Conclusions

In this single center experience, the use of EES was associated with reduced cardiac death and stent thrombosis. This benefit was mostly observed in the long‐term follow‐up.