Influência do quadro clínico nos resultados imediatos e tardios após aterectomia rotacional / Influence of the Clinical Presentation in Acute and Long-Term Results After Rotational Atherectomy

PURPOSE: To analyse the influence of unstable coronary syndromes (UCS) in the early and late prognosis after rotational atherectomy (RA). METHODS: We treated 236 patients with RA between Aug/1992 and May/1996. Patients were divided into two groups: A) stable coronary syndromes 120 (51) patients; B) UCS: 116 (49) patients. Definitions: 1) procedure success (PS)--lesion success in all locations were RA use was attempted, without a major complication; 2) late coronary events (LCE)--angina, MI, additional revascularization or death. RESULTS: There was a significant predominance of age > 70 (A = 14x B = 24, p = 0.03) in B and previous MI (A = 32x B = 11, p = 0.0001) in A. Other characteristics were similar in both groups, including complex lesions (type B2/C), which were observed in 77A stenosis and 80B lesions. PS was 95in A and 92in B (p = NS). In-hospital major complications were observed in 2.5A and 4.3B patients, (p = NS). One patient died in each group. A and B patients had similar time of follow-up. LCE occurred in 25A and 39B patients (p = 0.002). Recurrence of angina (36x 23; p = 0.01) and target lesion revascularization (29x 18; p = 0.03) were also more frequently required in B cases. CONCLUSION: This study suggests that UCS (group A) does not implicate in worse acute results after RA. However, UCS patients present greater incidence of late coronary events, particularly recurrence of angina and target-lesion revascularization.

Papel do endotélio na regulaçäo celular e no remodelamento vascular: implicaçöes na reestenose pós-angioplastia coronária / Role of the endothelium in the regulation of cell proliferation and vascular remodeling: implications for restenosis after coronary angioplasty

A reestenose representa a maior limitaçäo a longo prazo da angioplastia coronária. O endotélio vascular, além de desempenhar importante papel na regulaçäo do tônus vasomotor arterial, também é o principal mediador de dois processo biológicos extremamente importantes na gênese da reestenose coronária: a proliferaçäo das células musculares lisas e o remodelamento vascular. Além de sintetizar fatores estimuladores e inibidores do crescimento celular, o endolélio ainda é o responsável pela manuntençäo da trombo-resistência, impedindo a ativaçäo das plaquetas, outra importante fonte de mitogenos. O remodelamento vascular e um processo biológico atuante na aterosclerose e evidências recentes indicam que ele é um fator na determinaçäo di surgimento ou näo da reestenose. O endotélio também parece ser o mediador primário do desenvolvimento de alteraçöes estruturais da parede do vaso em resposta a fatores hemodinâmicos. Esses achado säo extremamente úteis para o melhor entendimento da patogenes da reestenose e , além disso, podem ter importantes implicaçöes no desenvolvimento de estratégias que visem o controle dessa complicaçäo da angioplastia coronária.

Angioplastia coronária em pacientes com lesoes reestenóticas. Caracterização do perfil clínico e angiográfico, evolução hospitalar e implicaçoes para seleção de pacientes / Coronary angioplasty in patients with restenotic lesions. clinical and angiographic profile, In-hospital outcome and implications for patient selection

PURPOSE--To define the clinical and angiographic profile of patients undergoing to a 2nd or a 3rd coronary angioplaty (PTCA) for the treatment of restenosis, and assess the safety and efficacy of redilatation. METHODS--Patients submitted to PTCA for a 1st (1stRE) or a 2nd (2ndRE) restenosis, from Jan/1980 through Dec/1993, were retrospectively identified, and compared to those undergoing to PTCA for de novo lesions (DN). RESULTS--A total of 5,736 underwent to dilatation of primary lesions, 610 of a 1stRE, and 64 of a 2ndRE. Patients with restenotic lesions had a higher prevalence of diabetes, smoking, history of prior infarction (1stRE e 2ndRE) and hyperlipidemia (2ndRE) as compared with primary lesions (p < 0.05). Besides patients with a 2ndRE had a higher incidence of left ventricular dysfunction, as compared to those with DN or a 1stRE (31.3 with EF < 45 in group 2ndRE, vs 19.8 and 23.1 in groups 1stRE and DN, respectively, p < 0.05). Primary success, infarct rate and mortality were similar in all groups, but emergency bypass surgery was significantly higher in the DN (2.1 vs 0.8 in 1stRE and 0 in 2ndRE, p < 0.05). CONCLUSION--Restenosis can be effectively treated by redilatation. Patients with clinical and angiographic features predisposing to further recurrence can be better treated with other interventions (i.e., coronary stents, bypass surgery).

Objetivo - Definir o perfil clínico e angiográfico dos pacientes submetidos à angioplastia coronária para tratar a 1ª ou 2ª recidiva e determinar os resultados dessa redilatação. Métodos -Identificar, retrospectivamente, os pacientes submetidos a uma 2g (1 gRE) ou 3ê (2-aRE) angioplastia para tratar reestenoses, entre jan/80 e dez/ 93, comparando-os com os submetidos à dilatação de lesões primárias (DN). Resultados - Um total de 5.736 haviam se submetido à dilatação de uma lesão primária, 610 de uma 1ª reestenose e 64 de uma 2ª reestenose. Pacientes com lesões reestenóticas apresentavam incidência significantemente maior de diabetes, tabagismo, história prévia de infarto (1ªRE e 2ªRE) e dislipidemia (2ªRE), que aqueles com lesões primárias (p<0,05). Além disso, os submetidos à 2ª recidiva apresentavam uma incidência significantemente maior de disfunção ventricular esquerda que os com 1ª reestenose ou lesões primárias (31,3 % com fração de ejeção <45% no grupo 2ªRE vs 19,8% no grupo 1ª RE e 23,1% no grupo DN, p<0,05). Os índices de sucesso, infarto e morte foram semelhantes nos 3 grupos; porém, a freqüência de cirurgia de emergência foi significantemente maior no grupo com lesões primárias (2,1% vs 0,8% no grupo 1ªRE e 0% no grupo 2ªRE, p<0,05). Conclusão - Pacientes com reestenose pós-angioplastia coronária podem ser tratados com segurança com nova dilatação. Determinados portadores de características clínicas e angiográficas predisponentes a novas recidivas possivelmen te se beneficiem mais se tratados com outras modalidades de revascularização do miocárdio

Oclusão aguda pós-angioplastia coronária. Manuseio precoce e evolução tardia / Acute Closure After Coronary Angioplasty. Management and Follow-Up

PURPOSE--Assess the efficacy of the different strategies employed in the management of acute closure and verify the late prognosis of patients who develop this complication. METHODS--From january 1987, through December 1990, 2315 consecutive patients underwent percutaneous transluminal coronary angioplasty (PTCA) in our Institution. We analyzed 100 patients who had had acute closure of the dilated vessel determining the total incidence of myocardial infarction and death, the effectiveness of the different treatment strategies and clinical and angiographic predictors of poor in-hospital outcome. Late follow-up was obtained in the hospital survivors. RESULTS--The incidence of acute myocardial infarction in the group of 100 patients was 57; death occurred in 12of the patients. Forty-one individuals were referred to emergency bypass surgery, 35 received clinical treatment and 24 underwent redilatation of the vessel. Those managed clinically had a higher incidence of myocardial infarction compared to the ones who underwent either redilatation or surgery (74.3versus 50and 48.8). The in-hospital mortality rate was significantly higher in patients with left ventricular ejection fraction < 45(44.4, p < 0.001) and in procedures involving the left anterior descending artery (20, p < 0.05); patients undergoing repeat dilatation had the lower death rate (4.2versus 8.6in the clinical group and 17.1in the surgical group). Late follow-up was obtained in 65 of 88 hospital survivors (mean follow-up = 17 months). Patients who underwent repeat dilatation were significantly less symptomatic in the follow-up than those who received medical therapy during the acute phase (89versus 60.9of patients without symptoms respectively, p < 0.05). Patients who were referred to surgery had also a tendency towards having less symptoms (87.5of asymptomatic patients in the late follow-up) although the difference was not statistically significant (0.01 > p > 0.05). CONCLUSION--Acute coronary occlusion is a serious complication of angioplasty and is associated with high rates of major complications (myocardial infarction, death). Low left ventricular ejection fraction and PTCA involving the left anterior descending are predictors of higher in-hospital mortality in patients with acute closure. Late outcome is less favourable in patients submitted to clinical treatment in the acute phase.

Complicaçöes atuais do cateterismo cardíaco: análise de 1000 pacientes / Current complications of heart catheterization: analysis of 1000 cases

Avaliar o imnpacto das novas técnicas de cateterismo cardíaco sobre a incidência de complicaçöes. Mil pacientes consecutivos submetidos a cateterismo cardíaco no período de agosto a dezembro de 1989 (739 cateterismos diagnósticos e 261 terapêuticos) acompanhados até a alta hospitalar. As complicaçöes foram classificadas segundo o tipo e a gravidade e correlacionadas à técnica do procedimento e à fraçäo de ejeçäo do ventrículo esquerdo (FEVE). Em 77,7% dos pacientes näo houve complicaçöes. Nos restantes (22,3%) as complicaçöes foramÑ leves (11,2%), moderadas (7,3%) e severas (3,8%). Entre as últimas, ocorreram ,5% de intercorrências vasculares graves, 0,1% de perfuraçäo cardíaca necessitando de cirurgia de emergência, 1,4% de arritmias severas, 0,4% de infarto agudo do miocárdio, 0,3% de edema agudo de pulmäo e 0,5% de mortalidade. Os estudos hemodinâmicos permanecem com índice relativamente baixo de complicaçöes, apesar do crescente número de procedimentos intervencionistas e da maior gravidade dos pacientes estudados