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

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

Accurate aortic valve annulus sizing has critical importance for the planning of percutaneous transcatheter aortic valve implantation (TAVI) in patients with severe aortic valve stenosis. Although there is a recommendation to perform the measurement during systole, little is known about the importance of the differences between systolic and diastolic dimensions of the annulus.

Methods

Consecutive patients referred for TAVI were evaluated with computed tomography for valve annulus sizing during systole and diastole. Area, circumference, minimum and maximum diameters, and their mean derived diameters were obtained in both phases of the cardiac cycle. Bland-Altman plots were constructed to evaluate the differences between the measures.

Results

The analysis included 41 patients with severe aortic stenosis. Mean area, circumference, and diameters were slightly greater in systole. However, in 35% of patients, diastolic dimensions were greater. These differences, although statistically significant, were small (the greatest difference of 0.6 mm in mean diameter). Bland-Altman plots showed good agreement between systolic and diastolic measurements on all parameters evaluated.

Conclusions

Small differences were observed in the systolic and diastolic dimensions of the aortic valve annulus with computed tomography scan, which, although statistically significant, probably do not impact the selection of prosthesis or the procedure outcome.

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

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.

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

Multiple congenital defects are traditionally corrected surgically, but nowadays can be treated percutaneously. There are few reports in the literature attesting to its efficacy and safety. We aimed to describe an experience with combined procedures to treat different congenital and structural defects, in a single therapeutic session.

Methods

Since 2007, different defects were treated in a single treatment session. All were selected by echocardiography. The procedures were performed using traditional techniques already described for each defect.

Results

Ten patients were treated, five males, aged 1-67 years, weighting 11-90 kilograms. The most prevalent isolated defect was patent ductus arteriosus (PDA, n = 5), followed by ostium secundum atrial septal defects (osASD, n = 4) and ventricular septal defects (VSD, n = 4). The most common combinations were VSD with PDA (n = 2) and VSD with osASD (n = 2). Two pulmonary valve stenosis were dilated with osASD and patent foramen ovale (PFO), and one aortic coarctation with PDA. Additionally, a left atrial appendage with PFO was occluded and an aortopulmonary fistula with PDA was embolized. All procedures were successful. The mean follow-up was 31 ± 28.1 months, with only two complications. There were no deaths.

Conclusions

The small number of reported cases showed that the combined procedures were safe and effective and can be reproduced by experienced operators in specialized centers and may be considered as the first therapeutic option in these patients.

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 post- coronary artery bypass graft patients, especially for therapeutic procedures.

Anomalous origin of coronary arteries is a rare congenital disorder, with an estimated incidence of 0.3 to 1.3% of patients referred for coronary angiography. Currently, its discussion still divides opinions, particularly regarding the therapeutic approach. We report the case of a 75 year-old woman who underwent cardiac catheterization, which showed the left main coronary artery with an anomalous origin next to the right coronary artery in the right coronary sinus and with a retroaortic course.

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.