Beyond Atherothrombotic Disease in Acute Coronary Syndrome

Abstract Half of the global population over 20 years of age will be affected by cardiovascular disease. Cardiovascular events in young people is challenging. Spontaneous coronary artery dissection is a non-traumatic and non-iatrogenic separation of the coronary arterial wall and is an uncommon and underdiagnosed cause of acute myocardial infarction predominately found in young women. Medical management has been more widely accepted, with percutaneous and surgery treatment reserved for precise indications. Optimal control of individual risk factors is essential in order to avoid recurrences.

Reperfusión mecánica simple en el infarto agudo de miocardio: Determinantes, implicaciones en el pronóstico y relación con la histología del trombo / Simple mechanical reperfusion in acute myocardial infarction: determinants, prognostic implications and relation with thrombus histology

La reperfusión mecánica simple (RMS) es la lograda en la angioplastia primaria al atravesar la oclusión en la arteria responsable de infarto con la guía intracoronaria. Para evaluar los determinantes de la RMS, su implicación en el pronóstico y su relación con la histopatología del trombo rescatado, fueron analizados los casos de 601 pacientes con infarto agudo de miocardio con elevación del segmento ST y oclusión total de la arteria responsable de infarto (flujo TIMI 0). Se consideraron dos grupos según la presencia de RMS, definida por la visualización de contraste distal a la lesión luego de atravesarla con la guía intracoronaria. Se realizó el análisis histopatológico de los trombos en un subgrupo de 160 pacientes tratados con tromboaspiración. En 303 (50.4%) pacientes se obtuvo RMS. La RMS se asoció a menor ventana al tratamiento (248 vs. 286 minutos, p = 0.001), menor deterioro de la función sistólica ventricular izquierda inicial y shock al ingreso (9.2 vs.16.4%, p = 0.008), mayor tasa de éxito (94.7 vs. 78.5%, p < 0.0001) y de rescate de trombos (70/81 vs. 27/79 pacientes, p < 0.0001). La arteria responsable de infarto más frecuente fue la coronaria derecha. La RMS se asoció con menor tamaño del trombo, menor concentración de leucocitos y eritrocitos y mayor contenido de células inflamatorias, cristales de colesterol y colágeno provenientes de la placa. La RMS es un predictor independiente de éxito y su relación con la anatomía del trombo podría redefinir la indicación de la tromboaspiración.

Simple mechanical reperfusion (SMR) is defined as reperfusion achieved after wire insertion at the occluded infarct-related artery in primary angioplasty. The determinants and prognostic implications of SMR and its relationship with the histopathology of the rescued thrombus were evaluated in 601 patients with acute myocardial infarction showing ST elevation and pre-procedural total occlusion of the infarct-related artery (TIMI flow 0). Two groups were considered according to the presence of SMR, defined as the visualization of contrast material after crossing the occlusion with the guide wire. SMR was achieved in 303 patients (50.4%) and was found to be associated with less time to treatment (248 vs. 286 minutes; p = 0.001), less deteriorated initial left ventricular function and shock at admission (9.2 vs. 16.4%; p = 0.008), higher successful rate (94.7% vs. 78.5%; p < 0,0001) and of higher rate of thrombus rescue: 70/81 vs. 27/79 patients (p < 0.0001). The right coronary artery was the most frequent infarct-related artery. Histopathology of the retrieved thrombi was available for 160 patients treated with thrombus aspiration. SMR was associated with smaller thrombus, lower contents of leukocytes and erythrocytes, and higher thrombus content of inflammatory cells, cholesterol and collagen crystals from the atheromatous plaque. SMR is an independent predictor of procedure success and its relationship with the anatomy of the thrombus could redefine the indication of thrombus aspiration.

Valor de la tomografía de coherencia óptica en el tratamiento guiado de la falla del stent: Presentación de un caso / Value of the optical coherence tomography in the treatment guided of the stent failure: Case report

Desde la llegada de los stents convencionales y farmacoactivos han disminuido considerablemente los eventos de revascularización quirúrgica, sin embargo la trombosis y reestenosis son 2 factores que, aunque han disminuido, permanecen como complicaciones importantes. Existen varios factores que predisponen a la trombosis y a la reestenosis intrastent. La angiografía convencional tiene serias limitaciones para determinar las causas de la falla del stent. La tomografía de coherencia óptica es una técnica sumamente sensible para determinar las causas de trombosis y reestenosis del stent.

Since the advent of bare metal and drug-eluting stents, the surgical revascularization have declined considerably, however the thrombosis and in-stent restenosis are important complications of these devices. There are several factors that predispose to thrombosis and in-stent restenosis. Conventional angiography has serious limitations to determine the causes of stent failure. Optical coherence tomography is a very sensitive technique to determine the cause of thrombosis and in-stent restenosis.

Masa cardíaca derecha: a propósito de un caso / Clinical case: right ventricular intracardiac mass

El presente caso clínico trata de una paciente mujer de 42 años, en quien se encuentra una masa intracardíaca del corazón derecho, que estudiada con imágenes derivadas de ecocardiografía de superficie y transesofágica lleva a la sospecha de trombo, que es confirmado tras excéresis quirúrgica. Se analizan las etiopatogenias posibles y diagnóstico diferencial de masas intracardíacas.

A 42 year old woman is found to have right ventricular of intracardiac mass through surface and transesophageal echocardiography. Characteristics of the mass suggest a thrombus which is confirmed at the time of surgical removal. Different etiologies and differential diagnosis of intracardiac masses is discussed.

Trombose tardia (3 anos e 9 meses) de stent Cypher / Late Stent Thrombosis (3 years and 9 months) after Cypher Implantation

A trombose tardia nos stents revestidos com drogas antiproliferativas é uma realidade a ser enfrentada. Ela ocorre com maior frequência dependendo do critério de trombose, do que em stents convencionais. A trombose pode se dar anos após o implante e mesmo em pacientes usando antiagregante plaquetário. O desfecho clínico pode ser dramático, entretanto, não sabemos ainda se este evento realmente aumenta a mortalidade, quando comparado ao stent convencional. Os autores relatam um caso de trombose de stent Cypher, quase quatro anos após o seu implante.

A trombose tardia nos stents revestidos com drogas antiproliferativas é uma realidade a ser enfrentada. Ela ocorre com maior freqüência, dependendo do critério de trombose, do que em stents convencionais. A trombose pode se dar anos após o implante e mesmo em pacientes usando antiagregante plaquetário. O desfecho clínico pode ser dramático, entretanto, não sabemos ainda se este evento realmente aumenta a mortalidade, quando comparado ao stent convencional. Os autores relatam um caso de trombose de stent Cypher, quase quatro anos após o seu implante.

incidence of late stent thrombosis after successful cypher stent implantation

Stent thrombosis is a rare but devastating complication of coronary stent implantation. Coronary stent deployment is associated with a low incidence of acute and sub-acute thrombosis. However, late stent thrombosis has been recognized clinically. The aim of this prospective study was to evaluate the incidence of late stent thrombosis in patients receiving sirolimus-eluting stents. One hundred patients [132 lesions] who underwent implantation of sirolimus eluting stents were selected. All patients were pre-medicated with 325 mg of aspirin, which was continued indefinitely. Anti-thrombotic regimens, including intravenous heparin and a loading dose of clopidogrel [300 mg] were given in the catheterization laboratory and clopidogrel 75 mg/day was continued for at least 6 months. In patients allergic to clopidogrel, ticlopidine at a dose of 250 mg twice daily was prescribed as a substitute. Late stent thrombosis was defined as myocardial infarction characterized by anginal symptoms with ST-elevation on the electrocardiogram and creatine kinase-MB elevation > 3 times the upper limit of normal with angiographic documentation of partial or total stent occlusion more than 30 days after sirolimus eluting stent implantation [while the stented segment was the culprit lesion]. Complete 2 year follow-up was available for all patients. Between 30 days to 2 years after sirolimus-eluting stent implantation, 2 patients [2%] experienced late stent thrombosis at a mean time of 420 days [range 360 to 480]. This study reports a very late stent thrombosis after 20 months of sirolimus eluting stent implantation and 15 months after cessation of clopidogrel treatment, despite continued aspirin administration. This study also implies the possible need for long term antiplatelet therapy among patients receiving sirolimus eluting stents

Aplicaciones del stent cubierto con membrana de politetrafluoroetileno en el intervencionismo coronario (Experiencia del Instituto Nacional de Cardiología "Ignacio Chávez") / Synthetic membrane coronary stent graft in coronary disease

El stent cubierto con membrana se ha reportado como un dispositivo útil para corregir lesiones angiográficas específicas, así como complicaciones potenciales secundarias a procedimientos de intervencionismo coronario. El stent cubierto con membrana de (Jostent-Jomed) está compuesto por una fina capa de politetrafluoroetileno (PTFE) que se localiza entre dos stents metálicos. En esta revisión retrospectiva el stent de PTFE se utilizó en varias lesiones y situaciones angiográficas tanto en arterias coronarias como en injertos venosos. Nuestra experiencia consistió de 17 pacientes que fueron tratados por diferentes indicaciones clínicas y angiográficas: perforación coronaria en dos pacientes (pts), injertos venosos con trombo y cambios degenerativos en ocho (pts), aneurismas coronarios en 4 (pts) y trombo grande refractario a tratamiento habitual en otros 3 casos. Nuestros resultados con el stent de PTFE mostraron una tasa de éxito clínico del 100% sin complicaciones durante la fase hospitalaria y en el seguimiento clínico a 10 ± 3 meses sólo tres pacientes tuvieron algún evento cardíaco adverso mayor. La indicación potencial para el implante del stent de PTFE en injertos venosos todavía no se ha puntualizado; sin embargo a la luz de varios estudios pareciera haber poco beneficio en esta circunstancia. Por otro lado la perforación y el aneurisma coronario parecen ser las indicaciones más recomendables para la aplicación de este dispositivo.

Summary The use of a synthetic membrane-covered stent has been suggested to overcome some specific lesions in coronary arteries and to solve some potential complications that could arise in any procedure of coronary intervention. A synthetic membrane coronary stent graft (JOSTENT-JOMED) is constituted by a membrane of polytetrafluoroethylene (PTFE), fixed between two thin metallic stents. In this clinical review of our laboratory's experience, the Jostent graft was used in several angiographic circumstances in coronary arteries or in vein grafts. Our clinical experience consists of 17 patients that were treated with placement of PTFE stents for different indications: coronary rupture in two patients; thrombus and degenerative vein grafts in eight patients, coronary aneurysms in four patients, and thrombus in coronary arteries in three more. Our clinical results with this device suggest that its implant is feasible and safe with a clinical success of 100% without complications during in-hospital stay; during the clinical 11 ± 3 months follow-up, only three patients exhibited major cardiac events. The indication for PTFE stent in vein grafts with degenerative and thrombus lesions has not been determined yet; however, recently, some randomized trials have shown little benefit in this circumstance. On the other side, coronary vessel rupture and coronary aneurysms are currently the most definitive indications.

Comisurotomía mitral percutánea en pacientes con estenosis mitral y trombos en la orejuela izquierda / Mitral valvotomy in patients with thrombus in the appendix of the left atrium

La comisurotomía mitral percutánea (CMP) es una alternativa terapéutica eficaz en el manejo de pacientes con estenosis valvular mitral (EM) y la presencia de trombos en la aurícula izquierda se ha considerado una contraindicación absoluta para su realización. El objetivo de este estudio es evaluar la seguridad de la CMP en pacientes con EM y trombos en la orejuela de aurícula izquierda (OAI). Entre septiembre de 1996 y de abril de 1997, realizamos diez procedimientos de CMP con técnica de Inoue en pacientes con EM sintomática y trombos en la OAI: nueve pacientes del sexo femenino y un masculino con edad media de 41 ñ 7.6 años. El Score de Wilkins fue 8 ñ 1.2. Antes del procedimiento todos recibieron anticoagulantes orales durante tres a doce meses sin desaparecer el trombo. Empleando ecocardiograma transesofágico y fluoroscopía se evitó el contacto de guías y catéteres con la OAI. Los procedimientos fueron terminados con éxito lográndose un incremento del área valvular mitral de 0.8 ñ 0.2 a 1.95 ñ 0.38 cm². No hubo ningún caso de embolia sistémica u otras complicaciones mayores durante la CMP ni a un año de seguimiento. Concluimos que la CMP es una anternativa terapéutica segura para el manejo de pacientes seleccionados con EM y trombos en la OAI