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

Background

Rotational atherectomy with new ablative strategies have been proposed for the treatment of extremely calcified lesions prior to stent implantation. Nevertheless, few data are available about the adoption of these new strategies in contemporary practice and about late outcomes of patients undergoing this therapy.

Methods

From July 2012 to November 2014, a retrospective single center registry was conducted, including all patients undergoing rotational atherectomy as part of the treatment of coronary arteries with heavy calcification or previous failed dilation. We evaluated technical aspects of atherectomy and late outcomes of patients for the occurrence of major adverse cardiovascular events (MACE), defined as death, Q-wave myocardial infarction or repeat target vessel revascularization.

Results

Twenty-nine patients with a mean age of 69.5 ± 7.6 years, underwent atherectomy. The average burr-to-artery ratio was 0.54 ± 0.07, the initial rotational speed was 161.000 ± 13.928 and the rate of cutting balloon utilization after atherectomy was 45.1%. Angiographic success was achieved in all procedures. The median follow-up time was 13.2 months (IQ: 4.0-17.4) and there were three events: 1 death of non- cardiac cause and 2 new target vessel revascularizations. The mean MACE-free survival time was 29.7 ± 2.1 months.

Conclusions

Contemporary rotational atherectomy incorporates less aggressive strategies of ablation with high rates of acute success and low occurrence of major adverse cardiovascular events during late follow-up.

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 a 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

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

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 iMAP^TM 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 iMAP^TM 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 iMAP^TM 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.

Background

The Xience V^TM everolimus-eluting stent is a new generation drug-eluting stent (DES) that incorporates a low profile cobalt-chromium platform (81 μm) and a highly biocompatible polymer (fluoropolymer), which carries and controls the release of everolimus. Recent studies have demonstrated sustained safety and efficacy of the Xience V^TM in the treatment of real-world populations. Our aim was to report the clinical results of 12 months of the BRAVO Brazilian protocol.

Methods

The BRAVO Registry was a prospective, non-randomized, single-arm, multicenter (25 centers) study that evaluated the late clinical results of 535 minimally selected patients treated with the drug- eluting stent Xience V^TM in Brazilian daily practice.

Results

Overall, 40% of patients had diabetes, 25% prior myocardial infarction, and 42% presented with acute coronary artery syndrome. The majority of lesions (69%) was highly complex (ACC/AHA type B2 or C). The mean length and the nominal stent diameter were 19.9 ± 5.3 mm and 3.0 ± 0.4 mm, respectively. The angiographic and procedural successes were 99.7 and 98%, respectively. At 12 months, the cumulative rate of major adverse cardiac events, available in 100% of patients, was 5.6% (cardiac death: 1.3%; acute myocardial infarction: 3.0%; revascularization of the target lesion: 2.2%). Stent thrombosis occurred in 5 patients (0,9%), and only 1 case was reported between 6 and 12 months.

Conclusions

The drug-eluting stent Xience V^TM demonstrated sustained safety and efficacy up to 12 months in the treatment of complex coronary lesions in patients from daily practice.

Background

In BIOACTIVE study, we evaluated vascular responses after the implant of biolimus A9-eluting stent (BES; BioMatrix^TM) and the everolimus-eluting stent (EES; XIENCE V^TM). In this study, we present the optical coherence tomography analysis (OCT) 6 months post-intervention.

Methods

Patients were randomized to treatment with BES (n = 22) or EES (n = 18). The primary outcome was the frequency of non-covered, poorly positioned struts by OCT.

Results

OCT was performed in 26 patients (BES: n = 15; EES: n = 11) and 749 tomographic images and 7,725 stent struts were analyzed. BES and EES showed similar luminal and stent areas. Neointimal hyperplasia area, neointimal thickness and the percentage of in-stent obstruction (8.44 ± 5.10% vs. 9.21 ± 6.36%; p = 0.74) were similar. The rates of not covered struts (BES: 2.10 ± 3.60% vs. ESS: 2.46 ± 2.15%, p = 0.77) and poorly positioned struts (BES: 0.48 ± 1.48% vs. EES 0.44 ± 1.05%, p = 0.94) were similarly low. The frequency of frames with signs consistent with peri-strut inflammatory infiltrate was low and similar between BES (15.53 ± 20.77%) and EES (11.70 ± 27.51%; p = 0.68).

Conclusions

The second-generation drug-eluting stents BES and EES were equally effective at suppressing the neointimal formation after 6 months, with favorable vascular responses. The frequency of frames with peri-strut infiltrate signals per patient was low, and lower than that observed historically with first-generation drug-eluting stents.

The anatomy of the coronary arteries is well known, but there is a wide variety in their origin and distribution. The dual left anterior descending artery is defined as the presence of two left anterior descending arteries within the anterior interventricular sulcus and is classified into four types. It is a benign anatomical variant that should be recognized, especially before interventional procedures. We report a patient with type I dual left anterior descending artery, with acute anterior wall ST elevation myocardial infarction, referred for primary percutaneous coronary intervention.

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 (rs = 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.