Estratégias Percutâneas em Doenças Estruturais: Foco em Insuficiência Cardíaca Crônica / Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure

Resumo As inovações em dispositivos ao longo das últimas décadas proporcionaram uma melhora no diagnóstico e tratamento de pacientes com insuficiência cardíaca. Essas novas ferramentas progressivamente adaptaram-se a estratégias minimamente invasivas e as opções percutâneas multiplicaram-se de forma rápida. No presente artigo revisamos as direções atuais e futuras dos dispositivos utilizados como opções adjuvantes para o diagnóstico e tratamento adjuvante na insuficiência cardíaca crônica, o seu desenvolvimento, mecanismos e estudos mais recentes

Abstract Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.

Aterectomia coronária com Excimer Laser como tratamento adjuvante da subexpansão grave do stent com calcificação volumosa / Excimer Laser coronary atherectomy as adjunctive treatment of severe stent underexpansion with bulky calcification

A aterectomia coronária com Excimer Laser melhorou significativamente nos últimos anos, utilizando emissão ultravioleta de alta energia e comprimento de onda curto, com menor penetração e menor emissão de calor, resultando em menos danos aos tecidos e menos complicações. Descrevemos o caso de um paciente do sexo masculino, 66 anos, ex-tabagista, hipertenso, diabético, dislipidêmico. Foi submetido a múltiplas intervenções coronárias percutâneas na artéria descendente anterior com stents não farmacológicos e farmacológicos. Na última intervenção coronária percutânea, o stent foi subexpandido, e o paciente apresentou trombose aguda do stent e reestenose recorrente do stent. Foram realizadas novas intervenções coronárias percutâneas com aterectomia coronária com Excimer Laser adjuvante, devido à angina refratária, com uso de carga progressiva e injeção de soro fisiológico, seguidas de posterior insuflação de balão de alta pressão e implante de stent farmacológico, com resultado excelente. No acompanhamento de 8 meses, o paciente se manteve assintomático.

Excimer Laser coronary atherectomy has improved significantly in recent years, emitting high-energy ultraviolet and short wavelength with less penetration and heat emission, ultimately leading to less tissue damage and fewer complications. We described a case of a 66-year-old male patient, former smoker and suffering from hypertension, diabetes mellitus, and dyslipidemia. He underwent multiple percutaneous coronary interventions in the left anterior descending artery with bare metal and drug-eluting stents. In the last percutaneous coronary intervention, the stent was underexpanded and the patient presented acute stent thrombosis and recurrent stent restenosis. New percutaneous coronary interventions with adjunctive Excimer Laser coronary atherectomy were undertaken due to refractory angina, using progressive load and saline injection, followed by subsequent high-pressure balloon inflation and drug-eluting stent implantation with an excellent result. At 8-month follow-up, the patient was asymptomatic.

Risk factors of transplant renal artery stenosis in kidney transplant recipients

Abstract Background: Transplant Renal Artery Stenosis (TRAS) is a recognized vascular complication after kidney transplantation. The overall risk predictors of TRAS are poorly understood. Methods: Retrospective analysis of patients with suspected TRAS (Doppler ultrasound PSV > 200 cm/s) who underwent angiographic study in a single center between 2007 and 2014. All patients with stenosis > 50% were considered with TRAS. Stenosis restricted in the body of the artery was also analyzed in a subgroup. Results: 274 patients were submitted to a renal angiography and 166 confirmed TRAS. TRAS group featured an older population (46.3 ± 11.0 vs. 40.9 ±14.2 years; p = 0.001), more frequent hypertensive nephropathy (30.1% vs. 15.7%; p = 0.01), higher incidence of Delayed Graft Function (DGF) (52.0% vs. 25.6%; p < 0.001) and longer Cold Ischemia Time (CIT) (21.5 ± 10.6 vs. 15.7 ± 12.9h; p < 0.001). In multivariable analyses, DGF (OR = 3.31; 95% CI 1.78-6.30; p < 0.0001) was independent risk factors for TRAS. DM and CIT showed a tendency towards TRAS. The compound discriminatory capacity of the multivariable model (AUC = 0.775; 95% CI 0.718-0.831) is significantly higher than systolic blood pressure and creatinine alone (AUC = 0.62; 95% CI 0.558-0.661). In body artery stenosis subgroup, DGF (OR = 1.86; 95% CI 1.04-3.36; p = 0.03) and Diabetes Mellitus (DM) (OR = 2.44; 95% CI 1.31-4.60; p = 0.005) were independent risk factors for TRAS. Conclusion: In our transplant population, DGF increased more than 3-fold the risk of TRAS. In the subgroup analysis, both DGF and DM increases the risk of body artery stenosis. The addition of other factors to hypertension and renal dysfunction may increase diagnostic accuracy.