Revista Brasileira de Cardiologia Invasiva (English Edition)最新文献

Background

Implantable cardioverter-defibrillators (ICDs) are usually indicated for patients with malignant arrhythmias considered as high risk. Sympathetic hyperactivity plays a critical role in the development, maintenance, and worsening of ventricular arrhythmias. New treatment options in this population represent a clinical necessity. This study's objective was to report the outcomes of patients with ICDs and electrical storm submitted to renal sympathetic denervation for arrhythmia control.

Methods

Eight patients with ICDs admitted for electrical storm refractory to optimal medical therapy underwent renal sympathetic denervation. Underlying diseases included Chagas disease (n = 6), non-ischemic dilated cardiomyopathy (n = 1), and ischemic cardiomyopathy (n = 1). Information on the number of episodes of ventricular tachycardia/ventricular fibrillation and antitachycardia therapies in the week before the procedure and 30 days after treatment were obtained through interrogation of the ICDs.

Results

The median numbers of episodes of ventricular tachycardia/ventricular fibrillation, antitachycardia pacing, and shocks in the week before renal sympathetic denervation were 29 (9 to 106), 23 (2 to 94), and 7.5 (1 to 88), and significantly reduced to 0 (0 to 12), 0 (0 to 30), and 0 (0 to 1), respectively, 1 month after the procedure (p = 0.002; p = 0.01; p = 0.003, respectively). No patients died during follow-up. There were no major complications related to the procedure.

Conclusions

In patients with ICDs and electrical storm refractory to optimal medical treatment, renal sympathetic denervation significantly reduced arrhythmia load and, consequently, antitachycardia pacing and shocks. Randomized clinical trials in the context of renal sympathetic denervation to control refractory cardiac arrhythmias are needed to further support these findings.

This report describes a patient with pulmonary hypertension secondary to schistosomiasis, who sought emergency care due to chest pain at rest. The clinical presentation and other information related to the case raised the suspicion of acute coronary failure, and a severe obstruction was identified in the left main coronary artery. The case report aimed to highlight the need for a differential diagnosis of chest pain complaints in these patients, and emphasizes the choice of percutaneous coronary intervention as an effective and safe treatment in this scenario.

Transcatheter aortic valve implantation (TAVI) is an alternative for patients with aortic stenosis at high surgical risk and for many of those considered inoperable. Despite its minimally invasive features, complications related to the procedure may occur. Coronary obstruction during TAVI is a rare (incidence rate of less than 1%) but potentially lethal complication. In Brazil, this complication was found in 0.72% of procedures – three of 418 cases from Brazilian Transcatheter Aortic Valve Implantation Registry – with an in-hospital mortality rate of 100%. This case report presents prevention and treatment measures for coronary occlusion after TAVI.

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.

Renal artery fibromuscular dysplasia is a condition of unknown etiology, with non-inflammatory, non-atherosclerotic origin, associated to the development of stenosis and aneurysms. The authors report a case of bilateral renal artery fibromuscular dysplasia associated with a large renal artery aneurysm, treated with balloon angioplasty and a multilayer stent.

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 wide morphological variety of coarctation of the aorta (CoA) and some complications resulting from the implantation of conventional stents has made the utilization of covered stents (CS) desirable. We describe our experience with the use of CS to treat CoA in children and adults.

Methods

The records of patients that received CS were retrospectively reviewed. The procedures were performed according to the established technique. Use of CS as primary treatment were assessed, as well as those deployed due to complications resulting from the initial procedure.

Results

Between 2007 and 2014, CS were used in 14 patients, 9 (64.3%) of whom were males. The mean age was 19.5 ± 10.5 years, and the mean weight 61.7 ± 25.5 kg. Bicuspid aortic valve was present in 74% of cases, and two patients had patent ductus arteriosus. Subatretic aortic coarctations were found in five patients. Eleven patients had systemic arterial hypertension, and 73% had normalized blood pressure levels after stent dilation. Implantation was possible in all cases. Primary implants were performed in ten (71.4%) patients with native coarctation and in four patients as a second device to correct problems originating from previous procedures. The mean time of follow-up was 51.7 ± 29.8 months. Three minor complications were related to procedures, and there were no deaths.

Conclusions

The use of CS was safe and effective in this small case series. Further studies focusing on the long-term evolution and the possibility of CS redilation are needed to support its use in children.

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.