Experiencia multicéntrica de implante valvular aórtico percutáneo discriminada por riesgo en centros de Latinoamérica / Multicenter Experience of Transcatheter Aortic Valve Implantation Stratified by Risk in Latin American Centers

RESUMEN Introducción: El implante valvular aórtico percutáneo ha sido valorado en diferentes escenarios del amplio espectro de la población portadora de estenosis aórtica grave sintomática. La elección del tipo de tratamiento parte de una evaluación del riesgo de un equipo multidisciplinario. Objetivos: El objetivo de este estudio fue analizar las características y conocer los resultados de los pacientes sometidos a IVAP en Latinoamérica según el riesgo. Material y métodos: Se incluyeron a partir de marzo de 2009 a diciembre de 2018 pacientes en forma continua del registro multicéntrico latinoamericano de implante valvular aórtico percutáneo. La indicación de implante valvular aórtico percutáneo fue realizada en cada caso por un equipo multidisciplinario local. Se estratifica la población en función del riesgo quirúrgico evaluado por el puntaje STS-PROM. Se definieron tres grupos en función de los puntos de corte del STS -PROM establecidos: riesgo alto (RA, mayor del 8%), riesgo intermedio (RI, entre el 4% y el 8%) y riesgo bajo (RB, menordel 4%). Resultados: Se incluyeron en el análisis 770 pacientes; la mitad era de sexo femenino (50,2%) con una mediana de edad de 81 años (RIC 75,6-85,7). Del total, 230 pacientes (29,8%) fueron incluidos en el grupo AR (STS-PROM medio 11 [9,3-16,7]); 339 pacientes (44%), al riesgo intermedio (STS-PROM medio 6 [4,8-6,71]); y los restantes 201 (26,1%), al bajo riesgo (STS-PROM medio 2,7 [2-3,24]). La proporción de pacientes de bajo riesgo se incrementó a lo largo del período del registro (ptrend 0,011). Se utilizó acceso femoral (95%), y fue percutáneo en el 69% de los pacientes. Se implantaron en el 80% válvulas autoexpandibles. Del total de válvulas implantadas, el 23% (n = 177) resultaron ser reposicionables sin diferencias a través de los grupos. No se evidenciaron diferencias en mortalidad a los 30 días (RA 10,4%, RI 6,48%, RB 5,9%, p: 0,154) Tanto en el RA como en el de RB se observó una reducción de la mortalidad (RA 13,7%-4,1%, p: 0,001; RB 11,7%-0%; p: 0,0023). Conclusiones: La estratificación de riesgo mediante puntajes quirúrgicos continúa representando una guía de gran utilidad, sin embargo la indicación de implante valvular percutáneo en el mundo real incorpora otros factores no contemplados en la puntuación clásica, que modifica nuestras decisiones en la práctica diaria.

SUMMARY Introduction: Transcatheter aortic valve implantation (TAVI) has been evaluated in different scenarios of the broad spectrum of patients with severe symptomatic aortic stenosis. The choice of treatment starts through a risk assessment guided by a multidisciplinary team. Purpose: The aim of this study was to analyze the population undergoing TAVI in Latin America according to their risk. Methods: From March 2009 to December 2018, consecutive TAVI procedures registered in the Latin American multicenter registry were included. The indication of TAVI was made in each case by a multidisciplinary team set up by each center. The population is stratified according to the surgical risk evaluated by the STS-PROM score. Three groups were defined, based on the established STS-PROM cut-off points: high risk (RA, higher 8%), intermediate risk (IR, between 4%-8%) and low risk (RB, lower 4%). Results: 770 patients were included in the analysis, resulting 50,2% female, with a mean age of 81 y/o (IQR 75.6-85.7). 29.8% were included in the AR group (STS-PROM 11 (9.3-16.7), 44% at intermediate risk (STS-PROM 6 (4.8-6.71) and 26.1% at low risk (STS-PROM 2.7 (2-3.24). The proportion of low-risk patients has increased significantly over the period of inclusion (ptrend 0.011). Femoral access (95%), being percutaneous in 69% of patients. Self-expanding valves were implanted in 80%. 23% of the valves were repositionable without differences across the groups. There was no differences in 30-day mortality (RA 10.4%, IR 6.48%, RB 5.9%, p 0.154). Reduction in mortality were observed (RA 13, 7-4.1%, p0.001; RB 11.7-0%; p 0.0023) during the analyzed period. Conclusions: Risk stratification through surgical "scores" continues to represent a very useful guide, however the indication of TAVI in the real world incorporates other factors not contemplated in the classical score, which modifies our decisions in daily practice.

Implementación de un programa de angioplastia coronaria ambulatoria en pacientes con riesgo incrementado / Implementation of an Ambulatory Percutaneous Coronary Intervention Program in Higher Risk Patients

RESUMEN: Introducción: La hipercolesterolemia familiar es una hiperlipidemia primaria. Se trata de un trastorno genético autosómico dominante del metabolismo de las lipoproteínas, caracterizado por concentraciones plasmáticas elevadas de colesterol unido a lipoproteínas de baja densidad y presencia de xantomas tendinosos, y está asociado con el desarrollo prematuro de enfermedad cardiovascular. Objetivos: Investigar la presencia de mutaciones en el principal gen asociado al desarrollo de hipercolesterolemia familiar (LDLR) en un grupo de pacientes identificados como "casos índices", de entre aquellos que concurren al Servicio de Lípidos del Hospital Universitario Fundación Favaloro con diagnóstico clínico de hipercolesterolemia familiar. Determinar la composición ancestral de la población estudiada. Material y métodos: Se estudió una población de 38 pacientes con diagnóstico clínico de hipercolesterolemia familiar. La región codificante y las zonas intrónicas adyacentes del gen LDLR se secuenciaron automáticamente por el método de Sanger. Se investigó el componente ancestral de la población estudiada a partir del análisis de 46 marcadores informativos de ancestralidad (AIM-Indel). Resultados: Se identificaron 50 variantes diferentes, de las cuales el 48% se consideraron patogénicas. Se logró establecer una correlación genotipo-gravedad del fenotipo en el 60,5% de los pacientes estudiados. El componente ancestral de la población estudiada fue predominantemente europeo, seguido de un componente nativo-americano y, en menor proporción, africano. Conclusiones: El análisis genético por secuenciación del gen LDLR en pacientes identificados como "casos índices" con diagnóstico clínico de hipercolesterolemia familiar permite correlacionar el dato genético con la gravedad del fenotipo observado clínicamente y efectuar un diagnóstico en cascada en los miembros de la familia que presentan los criterios de inclusión considerados.

ABSTRACT: Background: Familial hypercholesterolemia is a primary hyperlipidemia. It is an autosomal dominant genetic disorder of lipoprotein metabolism, characterized by elevated plasma low-density lipoprotein cholesterol and presence of tendon xanthomas, and is associated with early cardiovascular disease. Objectives: The aim of this study was to investigate the presence of mutations in the main gene associated with the development of familial hypercholesterolemia (LDLR) in a group of patients identified as "index cases" attending the Lipid Clinic of the Hospital Universitario Fundación Favaloro with clinical diagnosis of familial hypercholesterolemia. The ancestral composition of the study population was determined. Methods: We evaluated 38 patients with clinical diagnosis of familial hypercholesterolemia. Mutation screening of the LDLR gene coding regions and adjacent intronic areas was performed using Sanger sequencing. The ancestral component of the study population was investigated using 46 ancestry inference markers (AIM-Indel). Results: Fifty different variants were identified, 48% of which were considered pathogenic. A genotype-phenotype severity correlation was established in 60.5% of the patients evaluated. The ancestral component of the study population was predominantly European, followed by native-American and African in lower proportion. Conclusions: Genetic testing by LDLR gene sequencing in patients identified as "index cases" with clinical diagnosis of familial hypercholesterolemia allows the correlation between the genetic information and the severity of the clinical phenotype to a cascade testing of the family members presenting the inclusion criteria considered.

Tratamiento del seudoaneurisma femoral mediante la inyección local de trombina / Femoral Pseudoaneurysm Treatment by Local Thrombin Injection

Introducción: El seudoaneurisma es una complicación ocasional (0,05-0,5%) de los procedimientos intervencionistas cuando se utiliza el acceso femoral. El cierre con inyección local de trombina como alternativa al tratamiento quirúrgico luego de compresión manual fallida cuenta con escasos registros. Objetivo: Evaluar la seguridad y eficacia del cierre del seudoaneurisma femoral iatrogénico mediante la inyección local de trombina guiada por ecografía Doppler. Material y métodos: Entre marzo de 2007 y junio de 2016 se incluyeron 32 pacientes para tratamiento con inyección de trombina. Resultados: La edad media fue de 64,3 ± 10,2 años. La mayoría de los seudoaneurismas estuvieron asociados con la realización de cateterismos coronarios diagnósticos o terapéuticos (59,3%). Siete pacientes habían recibido tratamiento anticoagulante y 21 doble antiagregación plaquetaria. En todos los casos se intentó previamente el cierre por compresión manual. La media del diámetro mayor de los seudoaneurismas fue de 38 mm. Luego del tratamiento, la trombosis inmediata del saco ocurrió en 28 pacientes (87,5%), mientras que 4 pacientes requirieron una segunda inyección, lo que determinó un éxito del 96,8%. En un solo paciente este tratamiento no fue efectivo, con posterior conversión a reparación quirúrgica programada. La dosis media de trombina fue de 450 unidades. Un único paciente presentó complicación trombótica venosa que requirió terapia anticoagulante, con buena evolución clínica. Conclusión: El tratamiento del seudoaneurisma con inyección local de trombina guiada con eco-Doppler fue una alternativa terapéutica segura y eficaz para pacientes con seudoaneurisma femoral refractarios a la compresión manual.

Background: Pseudoaneurysm is a rare complication (0.05-0.5%) after interventional procedures using femoral access. There are few registries of local thrombin injection for pseudoaneurysm closure as an alternative treatment to surgery after failed manual compression. Objective: The aim of this study was to evaluate the safety and efficacy of iatrogenic femoral pseudoaneurysm closure with Doppler ultrasound-guided local thrombin injection. Methods: Thirty-two patients were included for thrombin injection treatment between March 2007 and June 2016. Results: Mean age was 64.3±10.2 years. Most pseudoaneurysms were associated with diagnostic or therapeutic cardiac cath-eterizations (59.3%). Seven patients had received anticoagulant treatment and 21, double antiplatelet therapy. In all cases, prior closure was attempted by manual compression. Mean pseudoaneurysm major diameter was 38 mm. Following treatment, immediate pseudoaneurysm sac thrombosis occurred in 28 patients (87.5%), while 4 patients required a second injection, resulting in 96.8% success rate. Treatment was not effective in only one patient, with subsequent conversion to programmed surgical repair. Mean thrombin dose was 450 units. Only one patient presented with venous thrombosis complication requir-ing anticoagulant therapy, with good clinical outcome. Conclusion: Doppler ultrasound-guided local thrombin injection was a safe and effective therapeutic alternative for pseudoa-neurysm treatment in patients with femoral pseudoaneurysm refractory to manual compression.

Optimización del tiempo puerta-balón mediante la implementación de un programa de mejora de procesos / Optimization of Door-to-Balloon Time Implementing a Process Improvement Program

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Clopidogrel versus prasugrel en síndrome coronario agudo tratado con angioplastia / Clopidogrel versus prasugrel in acute coronary syndrome treated with coronary angioplasty

Al uso del clopidogrel se han agregado nuevos antiagregantes como prasugrel y ticagrelor. El objetivo de este estudio fue comparar la incidencia de eventos isquémicos y hemorrágicos en pacientes que han recibido clopidogrel o prasugrel.Se incluyeron de manera consecutiva todos los pacientes con angioplastia durante la internación por síndrome coronario agudo entre diciembre 2011 y diciembre 2012.Fueron incluidos 398 pacientes. No se observaron diferencias en la mortalidad de causa cardiovascular (clopidogrel 2.5% vs. prasugrel 2.9%, p = 0.48). El grupo prasugrel presentó una reducción en la tasa de infarto (1.9% vs. 6.8%, p = 0.01) con sangrado totales (18.5% vs. 8.5%, p = 0.001) a expensas de sangrados menores (12.4% vs. 3.4%, p < 0.001), sin diferencia en sangrados mayores (p = 0.27) y sangrados con peligro de vida (p =.0.20). Por análisis multivariado los predictores independientes de mortalidad cardiovascular fueron edad (odds ratio 1.08, intervalo de confianza, IC, 95% 1.02-1.16, p = 0.02) insuficiencia renal (odds ratio 6.98, IC 95% 1.23-39.71, p < 0.0001). En cuanto al sangrado total se identificaron la edad (odds ratio 1.06, IC 95% 1.02-1.09, p = 0.002), elevación del segmento ST (odds ratio 1.99, IC 95% 1.05-3.79, p = 0.02), insuficiencia renal (odds ratio 3.32, IC 95% 1.62-6.78, p = 0.002) y utilización de prasugrel (odds ratio 3.97, IC 95% 1.87-8.41, p < 0.0001). La utilización de prasugrel se asocia a una menor tasa de infarto agudo de miocardio al año de seguimiento, con incremento de hemorragias menores. No se observaron diferencias significativas en la mortalidad cardiovascular entre ambos grupos.

Greater antithrombotic potency new antiplatelet agents have been added such as prasugrel (PR) and ticagrelor to the traditional use of clopidogrel (CL) in the treatment of acute coronary syndrome (ACS). This study was aimed at comparing the incidence of long term ischemic and hemorrhagic events in patients treated with CL or PR during hospitalization. Retrospective ACS data base analysis performed by our cardiology service was completed prospectively. There were consecutively included all patients with percutaneous coronary intervention (PCI) during hospitalization due to ACS from December 2011 thru December 2012. A total of 398 ACS patients who underwent PCI with stent implantation were recruited. No differences in cardiovascular related deaths were observed in both groups (PR 2.9% vs. CL 2.5%, p = 0.48). PR group showed less re-infraction (1.9% vs. 6.8%, p = 0.01) with more total bleedings (18.5% vs. 8.5%, p = 0.001) and minor bleedings (12.4% vs. 3.4%, p < 0.001) with no differences in major and life threatening bleedings (p = ns). Multivariate analysis showed that independent predictors of cardiovascular mortality were age (OR 1.08, CI 95% 1.02-1.16) and renal failure (OR 6.98, CI 95% 1.23-39.71). Independent predictors for total bleeding were age (OR 1.06, CI 95% 1.02-1.09),ST segment elevation myocardial infarction (OR 1.99, CI 95% 1.05-3.79), renal failure (OR 3.32, CI 95% 1.62-6.78) and prasugrel use (OR 3.97, CI 95% 1.87-8.41). Use of prasugrel, in the ACS that requires PCI with stent, is associated with a lower myocardial infarction a year after follow-up, and it also leads to an increase of milder hemorrhage. No significant differences were observed in the cardiovascular mortality of both groups.

Clinical and Functional Outcome of Percutaneous alcohol septal ablation in Obstructive Hypertrophic Cardiomyopathy / Resultados clínicos y funcionales de la ablación septal percutánea con alcohol en la miocardiopatía hipertrófica obstructiva

background: Percutaneous septal ablation is a therapeutic option for patients with obstructive hypertrophic cardiomyopathy refrac-tory to optimal medical therapy. However, results of initial persistence and long-term safety are still controversial. Objectives: The aim of this study was to report percutaneous alcohol septal ablation technique, clinical and functional outcome, cardiovascular events and its impact on long-term follow-up. Methods: A total of 23 patients were included in the study. Functional class (FC), left ventricular outflow tract gradient before and after the procedure and long-term cardiovascular events were evaluated. results: Median follow-up was 52 months (IR 33-72). All patients were in FC III or IV prior to the procedure, under maximum tolerated medical therapy. The procedure was successful in 91% of cases, with 85% of patients currently in FC I and 15% in FC II. Baseline left ventricular outflow tract gradient decreased from 75 mmHg (95% CI 51-89) to 25 mmHg (95% CI 10-37) (p <0.003) and with Valsalva maneuver from 118 mmHg (95% CI 88-152) to 38 mmHg (95% CI 16-69) (p <0.0002), persisting in the long-term follow-up. During hospitalization, two patients presented with complete atrioventricular block requiring permanent pacemaker implantation. No cardiovascular deaths occurred during follow up. Conclusions: Alcohol septal ablation is a promising option for the treatment of a selected population with hypertrophic obstructive cardiomyopathy, generating sustained clinical and functional improvement with low incidence of events in the long-term follow up.

Sobrevivência a médio prazo e estado funcional de pacientes com estenose valvar aórtica grave submetidos a implante transcateter da válvula aórtica / Medium-term survival and functional status of patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation

INTRODUÇÃO: O procedimento de implante transcateter da válvula aórtica (TAVI, do inglês transcatheter aortic valve implantation) representa opção de tratamento em pacientes com estenose valvar aórtica (EA) com risco cirúrgico elevado ou proibitivo. Relatamos nossa experiência usando o sistema autoexpansível Medtronic CoreValve®. MÉTODOS: No período de 2009 a 2013, 51 pacientes consecutivos com EA grave sintomática e risco cirúrgico alto ou proibitivo foram submetidos ao TAVI. Os resultados foram analisados de acordo com os critérios Valve Academic Research Consortium (VARC) -2. RESULTADOS: A média de idades dos pacientes foi 82 ± 6 anos, 49% eram do sexo feminino, 19% diabéticos, 21% tinham insuficiência renal e o EuroSCORE logístico foi 17,4 ± 11,4%. O sucesso do dispositivo foi alcançado em 84,3%. Todos os pacientes tiveram diminuição significativa dos gradientes transaórticos, que foi mantida ao longo do tempo. A internação hospitalar foi de 6 dias (intervalo interquartil: 5-8,8). A mortalidade intra-hospitalar e aos 30 dias foi 7,8% e 9,8%, respectivamente. Implante de marca-passo permanente foi necessário em 32,6% dos casos; acidente cerebrovascular isquêmico ocorreu em 3,9%; e complicações vasculares maiores em 6% dos pacientes. A sobrevivência aos 6 meses e em 1 ano foi 86,3% e 84,4%, respectivamente. A classe funcional NYHA melhorou significativamente após o TAVI e permaneceu baixa no seguimento de médio prazo. CONCLUSÕES: Nesta experiência preliminar, o tratamento de pacientes com EA e risco cirúrgico alto ou proibitivo com TAVI, usando o sistema autoexpansível CoreValve®, foi considerado viável e seguro, e levou à melhoria sustentável dos sintomas cardíacos. Após a superação dos riscos iniciais de morte e de acidente cerebrovascular, o procedimento garantiu um bom resultado clínico, no longo prazo.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with aortic valve stenosis (AS) and high or prohibitive surgical risk. We report our experience using the Medtronic CoreValveTM self-expending system. METHODS: From 2009 to 2013, 51 consecutive patients with severe symptomatic AS and high or prohibitive surgical risk were submitted to TAVI. Results were analyzed according to the criteria of the Valve Academic Research Consortium (VARC) -2. RESULTS: Mean age was 82 ± 6 years, 49% were female, 19% were diabetic, 21% had renal failure and the logistic EuroScore was 17.4 ± 11.4%. The success rate of the device was 84.3%. All of the patients had a significant decrease of transaortic gradients, which was maintained over time. Hospitalization time was 6 days (interquartile range: 5-8,8). In-hospital mortality at 30 days was 7.8% and 9.8%, respectively. Permanent pacemaker implantation was required in 32.6% of the cases, ischemic stroke was observed in 3.9% and major vascular complications in 6% of the patients. Survival at 6 months and 1 year was 86.3% and 84.4%, respectively. NYHA functional class improved significantly after TAVI and remained low in the medium-term follow-up. CONCLUSIONS: In this preliminary experience, the treatment of patients with AS and high or prohibitive surgical risk with TAVI, using the CoreValveTM self-expanding system was feasible and safe and led to sustained improvement of cardiac symptoms. After overcoming the initial risks of death and stroke, the procedure guaranteed good long-term clinical outcomes.

Tratamiento antiagregante guiado por pruebas de función plaquetaria en pacientes sometidos a angioplastia coronaria exitosa / Antiplatelet Therapy Guided by Platelet Function Testing after Successful Percutaneous Coronary Intervention / Antiplatelet Therapy Guided by Platelet Function testing after Successful Percutaneous Coronary Intervention Background

Introducción El tratamiento antiagregante dual con aspirina y clopidogrel constituye un tratamiento esencial para la prevención de eventos isquémicos en pacientes sometidos a angioplastia transluminal coronaria (ATC). Sin embargo, existe alta variabilidad interpaciente en la respuesta al clopidogrel, condicionando la falla en su efecto terapéutico, que se manifiesta como hiperreactividad plaquetaria residual (HPR). El prasugrel podría reducir este estado protrombótico. Objetivos 1) Estudiar la respuesta antiagregante en pacientes sometidos a ATC exitosa pretratados con clopidogrel o prasugrel y 2) evaluar la respuesta a una carga de prasugrel en pacientes con HPR bajo tratamiento con clopidogrel. Material y métodos Se incluyeron en forma prospectiva y consecutiva 83 pacientes sin riesgo hemorrágico alto sometidos a ATC exitosa bajo tratamiento antiagregante dual: aspirina más clopidogrel (600 mg de carga o mantenimiento de 75 mg/día por más de 7 días; n = 42) o prasugrel (60 mg de carga o mantenimiento de 10 mg/día por más de 7 días, n = 41). La selección de la tienopiridina quedó a cargo del médico tratante. La función plaquetaria se evaluó a las 12-24 horas pos-ATC con el método VerifyNow®. Se definió HPR a la presencia de ≥ 230 unidades de reactividad plaquetaria (URP). Los pacientes con HPR recibieron una dosis de carga de prasugrel de 60 mg y se repitió la evaluación de la función plaquetaria a las 2 horas. Resultados No hubo diferencias significativas en las características basales de ambos grupos. A las 12-24 horas pos-ATC, los pacientes tratados con prasugrel presentaron menos URP en comparación con el grupo clopidogrel [mediana 49 (9-78) vs. 160 (82-224); p < 0,001]. Se observó HPR en el 24% de los pacientes del grupo clopidogrel y cero en el grupo prasugrel (p < 0,001). Todos los pacientes con HPR bajo tratamiento con clopidogrel lograron corregirla luego de la carga de prasugrel. Conclusiones En pacientes sometidos a ATC exitosa, el tratamiento con prasugrel logró una mayor inhibición de la agregación plaquetaria (IAP) en comparación con la administración de clopidogrel. Por su parte, los pacientes con HPR bajo tratamiento con clopidogrel lograron alcanzar una IAP óptima con la administración adicional de prasugrel.

Dual antiplatelet therapy with aspirin and clopidogrel is an essential treatment to prevent ischemic events in patients undergoing percutaneous coronary intervention (PCI). However, a significant interindividual variability exists in response to clopidogrel treatment, which is responsible for failure in the therapeutic effect and in the development of high residual platelet reactivity (HRPR). Prasugrel could reduce this prothrombotic state. Objectives To evaluate: 1) the antiaggregant response in clopidogrel or prasugrel pretreated patients undergoing successful PCI, and 2) the response to prasugrel loading in patients with low residual platelet reactivity on clopidogrel therapy. Material and Methods Eighty three patients were prospectively included in the study. They underwent successful PCI under dual antiplatelet therapy: aspirin plus clopidogrel (600 mg loading dose or a maintenance dose of 75 mg for more than 7 days; n=42) or prasugrel (60 mg loading dose or a maintenance dose of 10 mg for more than 7 days; n=41). The selection of thienopyridine was left at the discretion of the treating physician. Patients with high hemorrhagic risk were excluded. Platelet function was tested 12-24 hours after PCI with the VerifyNowTM P2Y12 Assay. High residual platelet reactivity (HRPR) was defined as P2Y12-reaction units (PRU) ≥ 230. In case of HRPR, patients received a loading dose of prasugrel 60 mg and platelet function was reassessed 2 hours later. Results Baseline characteristics did not differ in patients who initially received clopidogrel or prasugrel. At 12-24 hours post PCI, patients treated with prasugrel presented significantly less PRU compared with the clopidogrel cohort (median 49 (9-78) vs. 160 (82-224); p < 0.001). HRPR was observed in 24% of patients in the clopidogrel group and in no patients in the prasugrel cohort (p < 0.001). All patients with HRPR on clopidogrel treatment corrected this value after the loading dose of prasugrel. Conclusions After successful PCI, prasugrel administration achieved greater platelet inhibition compared to clopidogrel. Moreover, in patients with high-on treatment platelet reactivity with clopidogrel, optimal platelet inhibition was accomplished by additional prasugrel administration.

Angiografía coronaria con técnica rotacional doble: eficacia y seguridad frente a la coronariografía convencional / Efficacy and safety of dual: axis rotational coronary angiography versus conventional angiography

Introducción La angiografía convencional (AC) es la técnica de referencia para el diagnóstico de la enfermedad coronaria. Sin embargo, requiere múltiples proyecciones ortogonales para determinar el grado de enfermedad. La técnica de angiografía rotacional dual (ARD) permite una única adquisición e inyección de contraste para cada coronaria, con potencial reducción del volumen de contraste y de la dosis de radiación. Objetivo Comparar ambas técnicas (AC vs. ARD) a través de la evaluación de cantidad de contraste, exposición a la radiación y eficiencia diagnóstica. Material y métodos El presente es un estudio prospectivo, consecutivo, autocontrolado de coronariografías electivas para comparar AC y ARD. Todas las angiografías fueron revisadas por dos hemodinamistas independientes (observador 1 y observador 2) para evaluar la concordancia entre ambos tipos de imágenes. Para prevenir un sesgo en la lectura de las imágenes, los observadores evaluaron primero las ARD y tres semanas más tarde hicieron lo propio con las AC. Resultados Con la ARD se observó una reducción en la utilización de contraste (33,29 ± 11,2 ml vs. 17 ± 5,4 ml; p < 0,01) y en la exposición a radiación del paciente (235,6 ± 76,8 mGy vs. 82,7± 46,6 mGy; p < 0,01) y del operador (5,7 ± 3,26 mSv vs. 2,48 ± 1,47 mSv; p < 0,04). Se observó una leve diferencia y una fuerte correlación en el número de lesiones, diámetro del vaso y porcentaje de estenosis entre ambos observadores y entre ambos métodos. La evaluación categórica del porcentaje de estenosis también demostró una concordancia adecuada. Conclusión La ARD reduce el uso de contraste y la exposición a radiación en comparación con la técnica convencional, sin alterar la eficiencia diagnóstica del estudio.

Efficacy and safety of dual-axis rotational coronary angiography versus conventional angiography Background Conventional coronary angiography (CA) is the gold standard for the diagnosis of coronary artery disease. However, this technique requires several orthogonal projections to determine the severity of the disease. Dual-axis rotational coronary angiography (DARCA) is a new technique which allows visualization of each coronary artery using a single contrast injection and obtains unique images. This technique has been shown to reduce both radiation and contrast exposure. Objective To determine the amount of contrast used, radiation exposure and diagnostic accuracy of DARCA compared to conventional CA. Methods We conducted a prospective, self-controlled study of consecutive patients undergoing elective coronary angiography to compare DARCA versus the conventional technique. All the angiographies were reviewed by two independent interventional cardiologists (observer 1 and observer 2) who evaluated agreement between both types of images. The observers evaluated firstly the DARCAs and three weeks later the conventional CAs to prevent bias in reading the images. Results The contrast volume used in the diagnostic procedure was significantly lower with DARCA (33.29±11.2 ml vs. 17±5.4 ml; p <0.01). Radiation exposure in patient (235.6±76.8 mGy vs. 82.7±46.6 mGy; p <0.01) and operator was also significantly lower (5.7±3.26 mSv vs. 2.48±1.47 mSv; p <0.04). A slight difference and a strong correlation were seen in the number of lesions, vessel diameter and percentage of stenosis between both observers and in both methods. Agreement for categorizing percentage of stenoses was also adequate. Conclusion DARCA reduces the use of contrast agent and radiation exposure compared to the conventional technique without modifying the diagnostic accuracy of the method.

Evaluación del puntaje SYNTAX por residentes de cardiología clínica / Evaluation of the SYNTAX score by residents in clinical cardiology

Introducción El puntaje SYNTAX (PS) se presenta como una herramienta útil para la selección de pacientes con enfermedad del tronco y/o de tres vasos pasibles de revascularización mediante angioplastia. Existe una moderada reproducibilidad interobservador entre miembros del estudio original. No se dispone de evidencia suficiente sobre la evaluación del PS por miembros ajenos a un laboratorio de cardiología intervencionista. Objetivos Evaluar si residentes de cardiología pueden realizar una valoración adecuada del PS y detectar posibles sesgos en ella. Material y métodos Se seleccionaron en forma retrospectiva cinecoronariografías que evidenciaban enfermedad del tronco y/o de tres vasos. Un residente de cardiología (RC) calculó el PS total para compararlo con lo calculado por un cardiólogo intervencionista (CI). Se analizaron los datos mediante el coeficiente kappa (deciles y terciles), el coeficiente de concordancia de Lin y gráficamente a través del método de Bland-Altman. Resultados Se analizaron 93 cinecoronariografías. Las medias del PS del CI y del RC resultaron de 28,58 (DE 10,0) y de 30,44 (DE 10,7), respectivamente. La diferencia de las medias fue de 1,85 (DE 7,01). El coeficiente kappa resultó de 0,57 (0,464-0,678) para deciles y de 0,60 para terciles (0,48-0,72). El coeficiente de Lin fue de 0,75 (0,65 a 0,83). El análisis de Bland-Altman detecta una tendencia del RC a infraestimar puntajes altos del CI. Conclusiones El presente trabajo demuestra una moderada a buena reproducibilidad interobservador entre un RC y un CI. Este nivel de acuerdo es tolerable para su cálculo según lo publicado. Se detectó una tendencia del RC a infraestimar PS altos.

Evaluation of the SYNTAX score by residents in clinical cardiology Background The SYNTAX score (SS) is a useful tool for selecting patients with left main or three-vessel coronary artery disease eligible for percutaneous coronary interventions. The score has moderate inter-observer reproducibility among members of the original study. There is not sufficient evidence about the evaluation of the SS by non-interventional cardiologists. Objectives To evaluate whether residents in cardiology can perform an adequate evaluation of the SS and to detect possible biases in this evaluation. Methods Coronary angiographies with evidence of main left coronary artery disease and/or three-vessel disease were retrospectively selected. A resident in cardiology (RC) calculated the total SS in order to compare it with the score calculated by an interventional cardiologist (IC). Data were analyzed using the kappa coefficient (deciles and tertiles), Lin's concordance correlation coefficient and Bland-Altman plot method. Results Ninety three coronary angiographies were analyzed. Mean SS calculated by the IC and the RC were 28.58 (SD 10.0) and 30.44 (SD 10.7), respectively. Mean difference was 1.85 (SD 7.01). The kappa coefficient was 0.57 (0.464-0.678) for deciles and 0.60 for tertiles (0.48-0.72). Lin's coefficient was 0.75 (0.65 to 0.83). The Bland-Altman analysis detected that the RC had a trend towards underestimating high scores calculated by the IC. Conclusions This study demonstrates a moderate to good inter-observer reproducibility between a RC and an IC. This level of agreement is tolerable to calculate the score, as previously published. A trend to underestimate high SS was detected in the RC.

Cierre percutáneo de la orejuela izquierda para prevención de tromboembolia en la fibrilación auricular / Percutaneous closure of left atrial appendage to prevent thromboembolism in atrial fibrillation

El accidente vascular encefálico embólico constituye la complicación más importante de la fibrilación auricular (FA) y el tratamiento anticoagulante es de elección para su prevención. Alrededor del 20% de los pacientes con FA presentan contraindicaciones de anticoagulación (ACO). La orejuela izquierda (OI) se ha identificado como el principal sitio de formación de trombos en la FA, especialmente en pacientes sin enfermedad valvular y sin deterioro de la función ventricular. La oclusión de la OI reduce la incidencia de eventos embólicos en este tipo de pacientes. En esta presentación se describe un caso de cierre percutáneo de la OI, con empleo del dispositivo Amplatzer Cardiac Plug. El paciente tenía riesgo embólico alto y contraindicación absoluta de ACO. El procedimiento se realizó en el Laboratorio de Hemodinamia, bajo guía radioscópica y ecocardiografía transesofágica, con anestesia general; se logró la oclusión completa de la OI. No se presentaron complicaciones durante el procedimiento y luego de un seguimiento de 3 meses, la OI se encuentra totalmente excluida y no se han evidenciado eventos embólicos.

Percutaneous closure of left atrial appendage to prevent thromboembolism in atrial fibrillation Embolic stroke is a major concern in atrial fibrillation (AF), and anticoagulation is the therapy of choice to prevent it. Around 20% of patients with AF have contraindications for anticoagulation (OAC). The left atrial appendage (LAA) has been identified as the most common place of thrombosis in patients with AF, particularly in those with non-valvular AF or impaired ventricular function. LAA occlusion reduces the incidence of embolic events in these patients. This article describes a case of percutaneous closure of LAA with the Amplatzer Cardiac Plug device. The patient was at high risk of embolism and had absolute contraindication for OAC. The procedure was performed at the cardiac catheterization laboratory under fluoroscopic guidance and transesophageal echocardiography, with general anesthesia; complete closure of the LAA was achieved. During the procedure, no complications were reported. The patient remained event-free at three-month follow-up, with complete exclusion of LAA. No embolic events have been reported.

Cierre percutáneo de fuga paravalvular mitral / Percutaneous Closure of Mitral Paravalvular Leak / Percutaneous Closure of Mitral Paravalvular Leak

El desarrollo de fuga paravalvular (FPV) luego del reemplazo valvular mitral es un fenómeno poco frecuente pero de gran repercusión sintomática. Debido a la elevada morbimortalidad de su abordaje quirúrgico se han intentado varias técnicas percutáneas con una tasa éxito que varía entre el 60% y el 90%. En esta presentación se describe el caso de una paciente joven, con múltiples cirugías valvulares mitrales previas, sintomática por disnea limitante y anemia hemolítica. Con el uso de imágenes ecocardiográficas tridimensionales, se realizó la oclusión de la FPV con un dispositivo Amplatzer III, diseñado específicamente para dicha indicación. Luego de un seguimiento de 3 meses, la FPV permanece totalmente excluida y la paciente se encuentra asintomática.

The development of mitral paravalvular leak (PVL) after mitral valve replacement is an uncommon complication with severe symptoms. The surgical repair of this condition has high morbidity and mortality; for this reason, several percutaneous techniques have been attempted with success rates between 60% and 90%. We describe the case of a young female patient with multiple mitral valve surgeries, who presented limiting dyspnea and hemolytic anemia. The PVL was closed using a specially designed Amplatzer III device under three-dimensional echocardiography. After 3 months of follow-up, the PVL remains completely excluded and the patient is asymptomatic.

Evolución alejada de la enfermedad renovascular aterosclerótica en pacientes sometidos a angioplastia / Long-Term Outcome of Atherosclerotic Renovascular Disease in Patients Treated with Angioplasty

Introducción El actual incremento en el diagnóstico de la enfermedad renovascular aterosclerótica (ERA) deviene del progresivo reconocimiento de su impacto clínico. El papel de la angioplastia renal percutánea como tratamiento alternativo ha motivado, y continúa haciéndolo, múltiples ensayos clínicos. Objetivos Analizar una población sometida a angioplastia renal percutánea y evaluar la seguridad del procedimiento y la respuesta clínica alejada. Material y métodos Se incluyeron en forma retrospectiva y consecutiva 100 pacientes intervenidos percutáneamente. Se realizó un seguimiento telefónico o por visitas (mediana 1,7 años; rango intercuartil 25-75, 1,2-2,7 años) durante el cual se recolectaron los datos clínicos y de laboratorio. Resultados Se analizaron 100 pacientes, la mayoría de sexo masculino (72%), edad media de 67,3 ± 9,9 años, con múltiples factores de riesgo cardiovascular (HTA 95%, DLP 74%, TBQ 63%, DM 28%) y amplio compromiso vascular aterosclerótico (enfermedad coronaria 56%, enfermedad vascular periférica 39%). Se realizó angioplastia con stent en el 98% de los casos, el 22% en forma bilateral, con un éxito del 99%. Se observó un descenso significativo de la tensión arterial sistólica (TAS) en el seguimiento alejado (TAS preprocedimiento 139,7 ± 24,2 mm Hg - TAS posprocedimiento 129,7 ± 13,9 mm Hg; p < 0,05), así como una reducción del número de drogas indicadas (2,8 ± 1,03 - 1,7 ± 0,9; p = 0,02). Estos resultados beneficiosos fueron incluso mayores en pacientes con compromiso bilateral. En relación con la función renal, el 49% de los pacientes evidenciaron una mejoría sostenida (depuración de creatinina: 53,6± 18,4 ml/min basal vs. 60,8 ± 19,5 ml/min al seguimiento; p = 0,011), mientras que el 20,4% presentó un deterioro importante en el filtrado glomerular. La mejoría en el filtrado glomerular fue más frecuente en pacientes con deterioro crónico avanzado (70,5% estadios ≥ III vs. 13,5% estadios 0-II; p = 0,01) y con angioplastia renal bilateral (depuración de creatinina: 52,8 ± 25,3 ml/min basal vs. 66,1 ± 15,1 ml/min al seguimiento; p = 0,032). En el análisis multivariado, la enfermedad renal grado ≥ III (OR 29,6, IC 95% 8,3-105,8; p > 0,001) y el sexo masculino (OR 16,2, IC 95% 4,3-105,8; p > 0,001) fueron predictores independientes de mejoría del filtrado glomerular en el seguimiento. Conclusiones El tratamiento percutáneo de la enfermedad renovascular es una alternativa terapéutica complementaria de elevada seguridad y buena evolución alejada en pacientes de riesgo alto. Se destaca asimismo el beneficio de la ATR en pacientes con deterioro renal basal importante, a pesar de una revascularización tardía.

Background The current increase in the diagnosis of atherosclerotic renovascular disease (ARD) results from the progressive recognition of its clinical impact. The role of percutaneous renal angioplasty as alternative therapy has been motivating several clinical trials. Objectives To analyze a population undergoing percutaneous renal angioplasty, and to assess the safety of the procedure and the long-term clinical response. Material and Methods A retrospective study of 100 consecutive patients treated with percutaneous surgery. Follow-up visits or telephone calls (median 1.7 years; interquartile range 25-75, 1.2-2.7 years) were performed, during which clinical and laboratory data were collected. Results A total of 100 patients were analyzed, most of them male subjects (72%), mean age of 67.3±9.9 years, with multiple cardiovascular risk factors (HBP 95%, DLP 74%, smoking 63%, DM 28%) and extensive atherosclerotic vascular involvement (coronary heart disease 56%, peripheral vascular disease 39%). Angioplasty with stent-graft was performed in 98% of the patients, 22% bilaterally, with a success rate of 99%. A significant reduction of systolic blood pressure (SBP) was observed at long-term follow up (preprocedural SBP 139.7±24.2 mm Hg - preprocedural SBP 129.7±13.9 mm Hg; p <0.05), and a reduction in the number of drugs indicated (2.8±1.03 - 1.7±0.9; p=0.02). These beneficial outcomes were even greater in patients with bilateral involvement. Regarding renal function, 49% of the patients showed sustained improvement (creatinine clearance: 53.6±18.4 ml/min basal vs. 60.8±19.5 ml/min at follow up; p=0.011), whereas 20.4% showed significant impairment in glomerular filtration. Improvement in glomerular filtration was more common in patients with advanced chronic impairment (70.5% stages ≥III vs. 13.5% stages 0-II; p=0.01) and with bilateral renal angioplasty (creatinine clearance: 52.8±25.3 ml/min basal vs. 66.1±15.1 ml/min at follow up; p=0.032). In multivariate analysis, renal disease degree ≥III (OR 29.6, CI 95% 8.3-105.8; p >0.001) and male sex (OR 16.2, CI 95% 4.3-105.8; p >0.001) were independent predictors of improved glomerular filtration at follow up. Conclusions Percutaneous treatment of renovascular disease is an additional therapeutic option, highly safe and with positive long-term outcomes in high risk patients. Benefits of the TRA in patients with significant baseline renal impairment should also be pointed out, despite the late revascularization.

Evaluación de las revascularizaciones coronarias denominadas inapropiadas por la nueva clasificación de adecuación de procedimientos en un centro cardiovascular de alta complejidad / Evaluation of Inappropriate Coronary Revascularization Procedures According to the New Classification in a Cardiovascular Tertiary Referral Center

Introducción Una revascularización coronaria inapropiada conlleva un riesgo muchas veces evitable para el paciente y se traduce en gastos innecesarios para el sistema de salud. Recientemente, los miembros de un panel de expertos en enfermedades cardiovasculares evaluaron el criterio de adecuación de la indicación de revascularización coronaria en varios escenarios clínicos comunes. Objetivos Identificar la proporción de revascularización coronaria inapropiada tanto percutánea (ATC) como quirúrgica (CRM) conforme al criterio de adecuación en un centro de alta complejidad cardiovascular. Material y métodos Desde enero hasta mayo de 2009 se incluyeron en forma consecutiva todos los pacientes derivados a nuestro centro con la indicación clínica de coronariografía que presentaron enfermedad coronaria significativa (estenosis ≥ 70%) y fueron sometidos a revascularización percutánea o quirúrgica. Se evaluó en este grupo la tasa de indicación inapropiada de revascularización coronaria conforme el criterio de adecuación recientemente publicado. Resultados De 568 cateterismos evaluados, 404 (71,2%) presentaron al menos una lesión ≥ 70% de estenosis, 81 pacientes fueron sometidos a CRM (20%) y 295 a ATC (73%). Del total de 376 pacientes revascularizados, la indicación de revascularización coronaria se consideró inapropiada en 15 (4%), todos ellos del grupo ATC (15/295; 5%), mientras que en el grupo de pacientes multiarteriales (n = 172) sólo 2 (1,2%) revascularizaciones resultaron inapropiadas. Conclusiones El criterio de adecuación de revascularización coronaria (percutánea o quirúrgica) en un centro cardiovascular de alta complejidad ha resultado inapropiado en una minoría de los casos. Dicho criterio representa una herramienta potencialmente aplicable tanto en la toma de decisiones en pacientes con enfermedad coronaria como en el control de calidad de los servicios de cardiología.

Background Inappropriate use of revascularization may be potentially harmful to patients and generate unwarranted costs to the health care system. Recently, the members of an expert panel conducted an appropriateness review of common clinical scenarios in which coronary revascularization is frequently considered. Objectives To identify the proportion of inappropriate coronary revascularization procedures -percutaneous (PTCA) and surgical (CABG) - in a cardiovascular tertiary referral center according to appropriateness criterion. Material and Methods We consecutively included all patients referred to our center for coronary angiography from January to May 2009 with a significant coronary stenosis (≥ 70%) who underwent percutaneous or surgical revascularization, and evaluated the rate of inappropriate revascularization according to appropriateness criterion recently published. Results From a total of 568 coronary angiographies, 404 (71.2%) had at least a coronary stenosis ≥70%; 81 patients underwent CABGS (20%) and 295 PTCA (73%). In these 376 revascularized patients, the indication was considered inappropriate in 15 (4%), all of them in the PTCA group (15/295; 5%), while only 2 patients with multivessel disease (n=172, 1.2%) underwent inappropriate revascularization. Conclusions In a cardiovascular tertiary referral center, the proportion of inappropriate coronary revascularization procedures (percutaneous or surgical) was low. Appropriateness criterion may be an applicable tool for decision-making in patients with coronary artery disease and for quality control in the departments of cardiology.

Gradientes intraventriculares e qualidade de vida no acompanhamento a longo prazo da redução não-cirúrgica do septo intraventricular na cardiomiopatia hipertrófica obstrutiva / Intraventricular gradients and quality of life in the long-term follow-up of nonsurgical intraventricular septum reduction in patients with hypertrophic cardiomyopathy

Introdução: Cerca de 30% dos pacientes com cardiomiopatia hipertrófica obstrutiva têm uma obstrução dinâmica do trato de saída do ventrículo esquerdo (TSVE). Pacientes sintomáticos são tratados com agentes inotrópicos negativos, entretanto alguns pacientes não respondem à terapia medicamentosa. A miectomia cirúrgica foi, até a década de 1990, o tratamento padrão para esses pacientes. A ablação septal percutânea com álcool (ASA) foi introduzida como terapia alternativa menos invasiva. Este estudo teve como objetivo avaliar a evolução clínica de pacientes submetidos a ASA em nosso centro.Método: Foram incluídos sete pacientes com cardiomiopatia hipertrófica obstrutiva, analisando-se os sintomas, os gradientes intraventriculares e a qualidade de vida antes e depois da ASA. O acompanhamento médio foi de 3,3 + 1,8 anos. Resultados: Houve melhora significativa da classe da New York Heart Association (NYHA) durante o acompanhamento clínico. O gradiente médio do TSVE antes da ASA, em repouso, foi de 67 + 22 mmHg, e com a manobra de Valsalva foi de 131 + 27 mmHg. Na evolução tardia, o gradiente médio do TSVE, em repouso, foi de 33 + 37 mmHg e com a manobra de Valsalva, 37 + 47 mmHg. O consumo máximo de oxigênio foi de 14,7 ml/min antes da ASA e durante o acompanhamento aumentou para 25,4 ml/min. Conclusão: Em nosso estudo, a ASA foi um tratamento seguro e eficaz para a cardiomiopatia hipertrófica obstrutiva, propiciando alívio substancial dos sintomas e da obstrução do trato de saída, e melhora da capacidade de exercício e da qualidade de vida, com baixas taxas de complicações.

Background: About 30% of patients with hypertrophic obstructive cardiomyopathy (HOCM) have dynamic obstruction of the left ventricular outflow tract (LVOT). Symptomaticpatients are treated with negative inotropic agents, however, some patients do not respond to medical therapy. Surgical myectomy was the standard therapy for these patients until the nineties. Percutaneous alcohol septal ablation (ASA) was introduced as a less invasive alternative therapy. This study was aimed at assessing the clinical course of patients undergoing ASA at our center. Method: Seven patients with HOCM were included and intraventricular gradients and quality of life before and after ASA were evaluated. Mean follow-up was 3.3 + 1.8 years. Results: There was a significant improvement in the NewYork Heart Association (NYHA) class during the followup. The mean LVOT gradient before ASA at rest was 67 +22 mmHg and 131 + 27 mmHg with Valsalva maneuver. In the late follow-up, the mean LVOT gradient at rest was33 + 37 mmHg and 37 + 47 mmHg with Valsalva maneuver. Peak oxygen uptake was 14.7 ml/min prior ASA, increasing to 25.4 ml/min during the follow-up. Conclusion: In our study, ASA was a safe and effective treatment for HOCM providing substantial relief of symptoms, outflow tract obstructionand improvement of exercise capacity and quality of life with low complication rates.

Tratamiento de la isquemia crítica de miembros inferiores / Treatment of Critical Lower Limb Ischemia

Introducción La isquemia crítica de miembros inferiores representa una manifestación extrema de la enfermedad vascular periférica crónica. La revascularización quirúrgica es el tratamiento de elección para los pacientes con esta patología, ya que pese a ser un procedimiento invasivo reduce la tasa de amputación y de mortalidad. Sin embargo, tiene una tasa alta de complicaciones. Durante la última década, el perfeccionamiento y la introducción de nuevas tecnologías percutáneas han derivado en un crecimiento importante en la estrategia endovascular. Su baja morbilidad comparada con la de la alternativa quirúrgica ha llevado a un rápido y explosivo incremento en su indicación. Objetivo Evaluar los resultados clínicos en pacientes con lesiones críticas de miembros inferiores tratados de forma endovascular en un centro de alto volumen. Material y métodos Desde enero de 2005 hasta diciembre de 2008 se realizaron 60 procedimientos en 55 pacientes. Resultados La edad de los pacientes fue de 72,5 ± 10,6 años (rango 49-91); el 60,7% eran de sexo masculino, el 57% padecían diabetes y el 48,8%, enfermedad coronaria. El 50% de los pacientes presentaron dolor del miembro en reposo y el resto, lesiones tróficas menores en el 41% y mayores en el 9%. Se trataron en total 74 lesiones: 14 aortoilíacas, 23 femoropoplíteas, 28 infrapoplíteas y 9 bypass vasculares. En el seguimiento a 30 días, la tasa de reintervención de urgencia fue del 10,9%, la de amputación del 5,4%, la de muerte del 3,6% y la de eventos cardíacos mayores (muerte, infarto agudo de miocardio, accidente cerebrovascular, reintervención o amputación) fue del 10,9%. Luego de 30 días, el seguimiento alejado (media 727 ± 442 días) arrojó las siguientes tasas: reintervención 11,7%, amputación 7,4%, infarto agudo de miocardio 2%, accidente cerebrovascular 2%, muerte 11,7% y eventos cardíacos mayores 27,4%. Las tasas de reintervención, amputación y eventos cardíacos mayores durante todo el estudio fueron del 21,4%, 14,3% y 30,3%, respectivamente. Conclusiones El tratamiento endovascular representa una alternativa atractiva para pacientes con isquemia crítica de miembros inferiores al reducir el riesgo de amputación. Sin embargo, esta población presenta un riesgo cardiovascular incrementado en el pronóstico alejado.

Background Critical lower limb ischemia is the extreme manifestation of chronic peripheral arterial disease. Surgical revascularization is the treatment of choice for patients with this condition as it reduces amputation and mortality rates despite being an invasive procedure. Yet, the incidence of complications is high. During the last decade, the development and introduction of new percutaneous technologies have enabled significant growth in endovascular strategies. Indications for endovascular treatment have increased due to its low morbidity compared to surgery. Objective To evaluate the clinical outcomes in patients with critical lower limb occlusions undergoing endovascular treatment in a high-volume center. Material and Methods A total of 60 procedures in 55 patients were performed from January 2005 to December 2008. Results Patients' age was 72.5±10.6 years (range 49-91) and 60.7% were men; 57% were diabetics and 48.8% had coronary artery disease. Fifty percent of patients had ischemic rest pain; 41% had minor trophic lesions and 9% presented major throphic lesions. A total of 74 occlusions were treated: 14 aortoiliac, 23 femoropopliteal, 28 infrapopliteal and 9 occlusions of vascular bypass grafts. The following outcomes were evaluated 30 days after the intervention: urgent reintervention, 10.9%; amputation, 5.4%; mortality, 3.6%; major cardiac events (mortality, myocardial infarction, stroke, reintervention or amputation), 10.9%. In the long-term follow-up (median 727±442 days) reintervention rate was 11.7%, amputation 7.4%, myocardial infarction 2%, stroke 2%, mortality 11.7%, and major cardiac events 27.4%. Reintervention, amputation and major cardiac events rates throughout the study were 21.4%, 14.3% and 30.3%, respectively. Conclusions Endovascular treatment represents an attractive option to reduce the risk of amputation in patients with critical lower limb ischemia. However, this population carries high long-term cardiovascular risk.

La glucemia en ayunas como predictor de mortalidad intrahospitalaria en pacientes con infarto agudo de miocardio sometidos a angioplastia primaria / Fasting Glycemia as a Predictor of In-Hospital Mortality in Patients with Acute Myocardial Infarction Undergoing Primary Angioplasty

Introducción El pronóstico de los pacientes que sufren un infarto agudo de miocardio con supradesnivel del ST (IAMST) ha mejorado notoriamente, en particular como resultado de la terapia de reperfusión. A pesar de estos avances, los pacientes con diabetes mellitus (DM) constituyen un grupo de alto riesgo. La hiperglucemia en pacientes con IAMST se asocia con peor pronóstico, independientemente del diagnóstico previo de DM. Objetivo Evaluar el valor pronóstico de la glucemia en ayunas (GA) durante un IAMST tratado con angioplastia primaria. Material y métodos De 227 pacientes con diagnóstico de IAMST se excluyeron 31 con DM y 7 derivados para terapia de rescate tardío. Se registraron la glucemia en la admisión (GAd) y la GA; la población se dividió según la GA en: grupo A ≥ 110 mg/dl (hiperglucémicos) y grupo B < 110 mg/dl (normoglucémicos). Resultados La población en estudio quedó conformada por 189 pacientes. La edad fue de 62,1 ± 10,5 años, sexo masculino 82%, tabaquistas 40%, el tiempo dolor-balón fue de 2,75 horas (25- 75% intercuartiles 2-4,75), el porcentaje con clasificación de Killip & Kimball (KK) ≥ 3 fue del 12,1% y el 38% presentaron localización anterior. Se registraron 15 (7,9%) muertes intrahospitalarias, todas en pacientes hiperglucémicos. Por análisis multivariado, los predictores independientes de mortalidad intrahospitalaria fueron la edad (p = 0,048) y la GA como variable continua (p = 0,002). Para los eventos cardíacos mayores (muerte, reIAM e insuficiencia cardíaca), la clasificación de KK ≥ 3 (p = 0,001), la GA (p = 0,001) y el deterioro moderado/grave de la función sistólica (p = 0,016) fueron sus únicos predictores independientes. La GAd no resultó predictora independiente de muerte o de eventos cardíacos mayores. Conclusiones Los resultados del presente estudio sugieren que la GA posee valor pronóstico a corto plazo en pacientes no diabéticos que cursan un IAMST. La GA identifica tempranamente y en forma sencilla a una población de riesgo alto.

Background The prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) has considerably improved, particularly due to reperfusion therapy. However, patients with diabetes mellitus (DM) constitute a high risk group. In patients with STEMI, hyperglycemia is associated with adverse prognosis, regardless of the previous diagnosis of DM. Objective To assess the prognostic value of fasting glycemia (FG) in patients with STEMI undergoing primary angioplasty. Material and Methods From a total of 227 patients admitted with STEMI, 31 patients with DM and 7 patients referred to rescue angioplasty were excluded. Glycemia at admission (GAd) and FG were registered; the population was divided according to FG: group A ≥110 mg/dl (hyperglycemic) and group B <110 mg/dl (normoglycemic). Results The study population comprised 189 patients. Mean age was 62.1±10.5years, 82% were men and 40% were current smokers; pain-to-balloon time was 2.75 hours (25-75% interquartile range: 2-4.75); 12.1% had a Killip & Kimball (KK) class ≥ 3, and 38% were anterior wall infarctions. Fifteen patients (7.9%) died during hospitalization; all deaths occurred in hyperglycemic patients. Multivariate analysis identified age (p=0.048) and FG (p=0,002) as independent predictors of mortality; KK class ≥ 3 (p=0.001), FG (p=0.001), and moderate to severe systolic dysfunction (p=0.016) were independent predictors of major cardiac events (death, reinfarction and heart failure). Glycemia at admission was not identified as an independent predictor of death or major cardiac events. Conclusions The results of the present study suggest that FG has a prognostic value in the short term in non diabetic patients with STEMI. Fasting glycemia is a simple tool for the early identification of a high risk population.

Uso de tromboaspiração em angioplastia coronária primária no mundo real: registro multicêntrico argentino de infarto agudo do miocárdio com supradesnivelamento do segmento ST / Real world use of thrombus-aspiration during primary angioplasty: argentinean multicenter registry of ST-elevation myocardial infarction

INTRODUÇÃO: O uso de tromboaspiração manual demonstrou melhorar a reperfusão miocárdica durante a intervenção percutânea primária. Entretanto, a população adequada para esse tratamento ainda não foi bem estabelecida. Este estudo teve como objetivo determinar a taxa de utilização e a seleção de pacientes para tromboaspiração manual durante intervenção percutânea primária. MÉTODO: No período de julho de 2008 a fevereiro de 2009, incluímos 183 pacientes com intervenção percutânea primária de oito centros argentinos em um registro prospectivo de infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). As características clínicas, angiográficas e do procedimento e os desfechos clínicos foram comparados entre os pacientes tratados com e sem tromboaspiração manual. RESULTADOS: A tromboaspiração manual foi utilizada em 20,8% dos pacientes. As características clínicas basais foram, em geral, semelhantes entre os pacientes tratados com e sem tromboaspiração manual. Entretanto, os pacientes tratados com tromboaspiração manual tinham pior função renal pré-procedimento e maior somatória de supradesnivelamento do segmento ST basal (12,2 ± 7,7 mm vs. 10,2 ± 8,6 mm; P = 0,06). O grupo com tromboaspiração manual apresentou maior proporção de pacientes com trombo graus 4-5 (86,8% vs. 49%; P < 0,01), maior fluxo TIMI 0 basal (tromboaspiração manual: 63,2% vs. 40,7%; P = 0,03), maior diâmetro do vaso (3,46 ± 0,5 mm vs. 3,12 ± 0,5 mm; P = 0,01), e maior utilização de filtro distal (13,1% vs. 0,7%; P = 0,04) e de balão intra-aórtico (10,5% vs. 3,4%; P = 0,05), assim como de inibidores da glicoproteína IIb/IIIa (39,5% vs. 14,5%; P = 0,04). A taxa de resgate de material aterotrombótico macroscópico foi de 76,3%. Embora o grupo com tromboaspiração manual apresentasse pico mais elevado de creatina fosfoquinase (tromboaspiração manual: 3.195,9 ± 2.598 UI/ml vs. 1.757,6 ± 1.806,6 UI/ml; P = 0,02), a porcentagem de resolução do segmento ST e o fluxo TIMI 3 final não foram diferentes entre os grupos. A taxa de eventos cardiovasculares adversos maiores no acompanhamento foi semelhante (21,1% vs. 15,2%; P = 0,36). CONCLUSÃO: O emprego da tromboaspiração manual na prática diária em paciente com IAMCSST destina-se a pacientes de maior complexidade tanto clínica como angiográfica, acarretando, no final, resultados clínicos semelhantes aos de pacientes não tratados com tromboaspiração manual.

BACKGROUND: Manual thrombus-aspiration has proven to improve myocardial reperfusion during primary percutaneous coronary intervention. However, the adequate population for this approach has not been well established. The aim of this study was to determine the frequency and patient selection for thrombus-aspiration during primary percutaneous coronary intervention. METHOD: From July 2008 to February 2009, we included 183 patients submitted to primary percutaneous coronary intervention from eight Argentinean centers in a prospective ST-segment elevation myocardial infarction (STEMI) registry. Baseline characteristics as well as clinical and angiographic outcomes were compared among patients treated with and without thrombus-aspiration. RESULTS: Manual thrombus-aspiration was used in 20.8% of the patients. Baseline clinical characteristics were similar among patients treated with and without thrombus-aspiration. However, thrombus-aspiration treatment was associated with worse baseline renal function and greater baseline ST-segment elevation (thrombus-aspiration: 12.2 ± 7.7 mm vs. 10.2 ± 8.6 mm; P = 0.06). The thrombus-aspiration group had a higher rate of patients with grade 4-5 thrombus (86.8% vs. 49%; P < 0.01) and baseline TIMI flow 0 (thrombus-aspiration 63.2% vs. 40.7%; P = 0.03), greater vessel diameter (3.46 ± 0.5 mm vs. 3.12 ± 0.5 mm; P = 0.01), use of distal filter (13.1% vs. 0.7%; P = 0.04) and use of intra-aortic balloon (10.5% vs 3.4%; P = 0.05), as well as glycoprotein IIb/IIIa inhibitor administration (39.5% vs. 14.5%; P = 0.04). Debris was retrieved from 76.3% of the patients. Although the thrombus-aspiration group had higher CK levels (thrombus-aspiration: 3195.9 ± 2598 UI/ml vs. 1757.6 ± 1806.6 UI/ml; P = 0.02), the percentage of ST-segment resolution and final TIMI 3 flow did not differ between groups. The follow-up rate of major cardiovascular events was similar for both groups (thrombusaspiration: 21.1% vs. 15.2%; P = 0.36). CONCLUSION: Routine thrombus-aspiration in patients with STEMI is used in patients with higher clinical and angiographic complexity, leading to similar overall clinical results as those not treated with thrombus-aspiration.

Reemplazo valvular aórtico percutáneo en pacientes de alto riesgo quirúrgico / Percutaneous Aortic Valve Replacement in High-Risk Patients

Una proporción importante de pacientes con estenosis aórtica (EAo) grave poseen comorbilidades que incrementan el riesgo de la cirugía de reemplazo valvular aórtico. El implante percutáneo de válvula protésica surge como una alternativa en este grupo de pacientes. Se comunican dos casos de pacientes de edad avanzada portadores de EAo grave a los que se les realizó con éxito el implante percutáneo de una prótesis valvular aórtica CoreValve y se describen los criterios para la selección de pacientes y la técnica de implante percutáneo.

A significant proportion of patients with severe aortic stenosis (AS) have comorbidities that increase the risk of surgical aortic valve replacement. Percutaneous implantation of an aortic valve prosthesis emerges as an alternative in this group of patients. We report two cases of elderly patients with severe aortic stenosis that underwent successful percutaneous implantation of CoreValve aortic valve prostheses; in addition, criteria for patient selection and the technique of the procedure are described.