Dolor torácico y alteración electrocardiográfica / A man with anginal pain and an abnormal EKG

A 57 year-old man, smoker, with high blood pressure, presented to the emergency unit with intermittent and brief typical anginal pain in the preceding 2 days. Baseline physical examination was normal. Figure 1 depicts de EKG recorded upon admission. Biomarkers for acute coronary syndrome were negative.

Comparison of Paclitaxel-Coated Balloon Treatment and Plain Old Balloon Angioplasty for De Novo Coronary Lesions

PURPOSE: This study compared the angiographic outcomes of paclitaxel-coated balloon (PCB) versus plain old balloon angioplasty (POBA) treatment for de novo coronary artery lesions. At present, there is no available data comparing the efficacy of PCB versus POBA for the treatment of de novo coronary lesions. MATERIALS AND METHODS: This multicenter retrospective observational study enrolled patients with de novo coronary lesions with a reference vessel diameter between 2.5 mm and 3.0 mm and lesion length or =50%) in POBA, compared to PCB (30.4%, n=7 vs. 4.1%, n=2, p<0.001). Target vessel revascularization was higher in the POBA group (13.0%, n=3 vs. 0%, p=0.033). CONCLUSION: PCB treatment of de novo coronary lesions showed better 9-month angiographic outcomes than POBA treatment alone.

Percutaneous Coronary Intervention Is More Beneficial Than Optimal Medical Therapy in Elderly Patients with Angina Pectoris

PURPOSE: Data comparing the clinical benefits of medical treatment with those of percutaneous coronary intervention (PCI) in an elderly population with angina pectoris are limited. Therefore, we evaluated the efficacy of elective PCI versus optimal medical treatment (OMT) in elderly patients (between 75 and 84 years old) with angina pectoris. MATERIALS AND METHODS: One hundred seventy-seven patients with significant coronary artery stenosis were randomly assigned to either the PCI group (n=90) or the OMT group (n=87). The primary outcome was a composite of major adverse events in the 1-year follow-up period that included cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and stroke. RESULTS: Major adverse events occurred in 5 patients (5.6%) of the PCI group and in 17 patents (19.5%) of the OMT group (p=0.015). There were no significant differences between the PCI group and the OMT group in cardiac death [hazard ratio (HR) for the PCI group 0.454; 95% confidence interval (CI) 0.041-5.019, p=0.520], myocardial infarction (HR 0.399; 95% CI 0.039-4.050, p=0.437), or stroke (HR 0.919; 95% CI 0.057-14.709, p=0.952). However, the PCI group showed a significant preventive effect of the composite of major adverse events (HR 0.288; 95% CI 0.106-0.785, p=0.015) and against the need for coronary revascularization (HR 0.157; 95% CI 0.035-0.703, p=0.016). CONCLUSION: Elective PCI reduced major adverse events and was found to be an effective treatment modality in elderly patients with angina pectoris and significant coronary artery stenosis, compared to OMT.

A Meta-analysis of Ostial and Trunk versus Distal Lesions in Unprotected Left Main Coronary Artery Stenting.

Aims: To assess outcomes for percutaneous coronary intervention (PCI) in ostial and trunk versus distal unprotected left main coronary artery (LMCA) lesions in the drugeluted stent (DES) era. Study Design: A meta-analysis and systematic review. Methods: With the help of a librarian, we searched Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Clinical Trials Registry from 2001 to July 2012. We included studies that enrolled ≥ 50 patients and had ≥6 months of follow-up. Our co-primary endpoints were the incidence of major adverse cardiac events (MACE) and target lesion/vessel revascularization (TLR/TVR). Data was abstracted and analyzed by two independent reviewers and differences were resolved by consensus. We assessed the results for heterogeneity in our analysis by examining the forest plots and then calculating a Q statistic, which we compared with the I2 index. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed-effects model; otherwise the random-effects model was used. Results: We identified 11studies involving 3,718 patients. Mean duration of follow-up was 29 months (range 12-62months). Compared with ostial and trunk stenting, distal LMCA PCI was associated with increased MACE (OR 1.95, 95% CI 1.43-2.66) and TLR/TVR (OR 3.13, 95% CI 1.90-5.16).No significant differences were detected for cardiac death (OR 1.06, 95% CI 0.72-1.58, p=0.58), MI (OR 1.15, 95% CI 0.74-1.77, p=0.80) or stent thrombosis (OR 1.57, 95% CI 0.90-2.77, p=0.41). Conclusion: Patients with ostial and trunk LMCA lesions treated with DES have better outcomes than patients with distal lesions. Our findings may support unprotected nondistal LMCA stenting as a primary approach in selected patient subsets.

Long-term outcomes of simple crossover stenting from the left main to the left anterior descending coronary artery

BACKGROUND/AIMS: Although complex bifurcation stenting in patients with non-left main (LM) bifurcation lesions has not yielded better clinical outcomes than simpler procedures, the utility of complex bifurcation stenting to treat LM bifurcation lesions has not yet been adequately explored. METHODS: In the present study, patients who underwent LM-to-left anterior descending (LAD) coronary artery simple crossover stenting to treat significant de novo distal LM or ostial LAD disease, in the absence of angiographically significant ostial left circumflex (LCX) coronary artery disease, were consecutively enrolled. The frequencies of 3-year major adverse cardiovascular events (MACEs; cardiac death, myocardial infarction, and target lesion revascularization), were analyzed. RESULTS: Of 105 eligible consecutive patients, only 12 (11.4%) required additional procedures to treat ostial LCX disease after main vessel stenting. The mean percentage diameter of ostial LCX stenosis increased from 22.5% +/- 15.2% to 32.3% +/- 16.3% (p < 0.001) after LM-to-LAD simple crossover stenting. The 3-year incidence of MACEs was 9.7% (cardiac death 2.2%; myocardial infarction 2.2%; target lesion revascularization 8.6%), and that of stent thrombosis 1.1%. Of seven cases (7.5%) requiring restenosis, pure ostial LCX-related repeat revascularization was required by only two. CONCLUSIONS: Simple crossover LM-to-LAD stenting without opening of a strut on the LCX ostium was associated with acceptable long-term clinical outcomes.

Utilização do fluxo fracionado de reserva do miocárdio para identificar variáveis preditoras de pior prognóstico após intervenções coronárias percutâneas / Use of myocardial fractional flow reserve to identify predictors of poor prognosis after percutaneous coronary interventions

INTRODUÇÃO: Vários estudos foram realizados para definir preditores de eventos adversos pós-intervenção coronária percutânea (ICP). Pacientes cujo fluxo fracionado de reserva do miocárdio (FFR) pós-procedimento é < 0,90 apresentam índice de eventos cardíacos adversos maiores em 6 meses pelo menos 3 vezes maior do que aqueles cujo FFR é ≥ 0,90. Este estudo teve por objetivo identificar fatores clínicos, angiográficos e do procedimento associados a FFR pós-ICP < 0,90. MÉTODOS: Foram incluídos 193 pacientes (256 lesões) tratados entre 2004 e 2005, e o FFR foi medido antes e depois da ICP em todos os vasos tratados. Os pacientes foram divididos nos grupos FFR < 0,90 e FFR ≥ 0,90. Análise multivariada por regressão logística foi utilizada para determinar as razões de chances (odds ratio - OR) ajustadas. RESULTADOS: Foi possível obter o FFR em todas as lesões. Não se observou diferença nos parâmetros clínicos entre os dois grupos de pacientes. Houve diferença em alguns parâmetros angiográficos e do procedimento, porém, ao aplicarmos o modelo de regressão logística, a única variável que se associou com FFR pós-ICP < 0,90 foi o tratamento da artéria descendente anterior (OR = 12,1; IC 95% 6,4-22,9; P < 0,01). CONCLUSÕES: A única variável preditora de FFR pós-ICP < 0,90 foi o tratamento da artéria descendente anterior.

BACKGROUND: Several studies were performed to define predictors of adverse events after percutaneous coronary intervention (PCI). Patients whose post-procedure myocardial fractional flow of reserve (FFR) is < 0.90 have an incidence of major cardiac events at 6 months at least 3 times higher than those whose FFR is ≥ 0.90. The aim of this study was to identify clinical, angiographic and procedure-related factors associated with a post-PCI FFR < 0.90. METHODS: One hundred and ninety-three patients (256 lesions) treated between 2004 and 2005 were included, and FFR was measured before and after PCI in all of the treated vessels. Patients were divided into groups with FFR < 0.90 and FFR ≥ 0.90. Logistic regression multivariate analysis was used to determine the adjusted odds ratio (OR). RESULTS: FFR was measured in all lesions. No difference was observed in clinical parameters between groups. There were differences in angiographic and procedure-related parameters, however, when the logistic regression model was used, the only variable associated to post-PCI FFR < 0.90 was the treatment of the left anterior descending artery (OR, 12.1; 95% CI, 6.4-22.9; P < 0.01). CONCLUSIONS: The only predictor of a FFR < 0.90 after PCI was the treatment of the left anterior descending artery.

Comparison of Bypass Surgery with Drug-Eluting Stents in Diabetic Patients with Left Main Coronary Stenosis

PURPOSE: Several studies have compared the effects of coronary stenting and coronary-artery bypass grafting (CABG) on left main coronary artery (LMCA) disease. However, there are limited data on the long-term outcomes of these two interventions in diabetic patients. MATERIALS AND METHODS: We evaluated 56 patients with LMCA stenosis who underwent drug-eluting stent (DES) implantation and 116 patients who underwent CABG in a single hospital in China between January 2004 and December 2006. We compared long-term major adverse cardiac events (death; a "serious outcome" composite of death, myocardial infarction, or stroke; and target-vessel revascularization). RESULTS: In-hospital (30-day) mortality was 0% for the DES group and 3.4% for the CABG group (p=0.31). There was no difference between the two groups in terms of risk of death [hazard ratio for stenting group, 0.49; 95% confidence interval (CI), 0.13-1.63; p=0.55] or risk of serious outcome (hazard ratio for DES group, 1.11; 95% CI, 0.39-1.45; p=0.47). The target-vessel revascularization rate was higher in the DES group than in the CABG group (hazard ratio, 3.67; 95% CI, 1.24-11.06; p=0.018). CONCLUSION: In this cohort of diabetic patients with LMCA stenosis, there was no difference in composite endpoints between patients receiving DESs and those undergoing CABG. However, stenting was associated with higher rates of target-vessel revascularization than CABG. DES implantation in diabetic patients with LMCA disease was found to be at least as safe as CABG.

Intervenciones coronarias percutáneas guiadas con medición de flujo de reserva coronario / Percutaneous coronary intervention guided by measurement of coronary flow reserve

Introducción: La revascularización de una estenosis coronaria que induce isquemia mejora el estatus funcional del paciente y su pronóstico. Por el contrario, la angioplastía de una lesión que no provoca isquemia puede implicar complicaciones sin beneficios. La medición de flujo de reserva coronario (FFR) es un índice del significado fisiopatológico de las estenosis coronarias. Objetivos: Comparar los eventos cardiovasculares adversos mayores (MACE) en pacientes en quienes la FFR permitió excluir una o más lesiones de angioplastia (Grupo FFR >0,75) con aquellos en que ésta obligó a la revascularización (grupo FFR < 0,75). Métodos: Estudio observacional en 74 pacientes derivados para angioplastía entre agosto de 2006 y julio de 2010. Se realizó medición de FFR con ade-nosina a lesiones de severidad intermedia (60-70 por ciento). Una FFR translesional <0,75 se consideró significativa para isquemia y subsidiaria de angioplastía. Se hizo un seguimiento de los MACE definidos como: muerte, infarto, necesidad de revascularización y/o presencia de angor. Resultados: 35 pacientes (47,3 por ciento) constituyeron el Grupo FFR >0,75, y en ellos disminuyó el porcentaje de lesiones múltiples angiográficamente significativas (dos o más vasos), desde un 51,4 por ciento (previo a la realización de FFR), a un 25,7 por ciento. En este grupo se utilizó un promedio de 0.7 stents por paciente, mientras que en el grupo FFR <0,75 (39 pacientes), este fue de 1.5 stents. Se efectuó un seguimiento promedio de 21,5 meses. Diecinueve pacientes (25,6 por ciento) desarrollaron MACE (28 eventos). No hubo fallecidos ni diferencias significativas en el análisis multifactorial en cuanto a infartos o angor, pero sí en la necesidad de nueva revascularización, siendo ésta significativamente mayor en el grupo FFR <0,75 (12,8 por ciento versus 2,9 por ciento, p=0,047). Conclusiones: La medición del FFR permite, en caso de descartar isquemia, disminuir la necesidad de angioplastías...

The treatment of coronary stenosis causing myocardial ischemia improves functional capacity and prognosis. Treatment of non-ischemia inducing coronary stenosis may lead to complications with no benefit to the patient Measurement of coronary flow reserve (CFR) may be used to assess the significance of coronary artery stenosis. Aim: To compare major adverse cardiovascular events (MACE) in patients with significant stenosis (CFR < 0.75), with those in which one or more stenosis was not significant (CFR > 0.75) and thus were not subjected to PTCA in the corresponding artery. Methods: 74 patients were included from August 2006 to July 2010. CFR was measured in lesions exhibiting 6070 percent stenosis, using adenosine. A value <0.75 was considered significant and led to PTCA. Patients were followed for death, myocardial infarction, revascularization and/or angina. Results: 35 patients (47 percent) constituted the >0.75 CFR group. After evaluation of CFR the number of significant coronary stenosis decreased from 51.4 percent to 25.7 percent. They received a mean of 0.7 stents per patient. On the other hand, in the group with CFR <0.75 (39 patients) the mean number of stents was 1.5. Patients were followed for a mean of 21.5 months. 28 MACE events were observed in 19 patients (25.6 percent). No deaths were observed. Multivariable analysis revealed no significant difference between groups regarding myocardial infarction or angina. The need for myocardial revascularization was greater in the CFR <0.75 group compared to the CFR >0.75 group (12.8 percent vs 2.9 percent, respectively, p=0.047). Conclusion: The exclusion of myocardial ischemia as inferred by a CFR >0.75 allowed a significantly lower number of PTCAs without increase in MACE at a medium term follow up. A greater number of revascularization procedures was required in patients with CFR <0.75, which is expected from the greater number of lesions subjected to PTCA.

Predictors of restenosis after percutaneous coronary intervention using bare-metal stents: a comparison between patients with and without dysglycemia

The objective of this study was to identify intravascular ultrasound (IVUS), angiographic and metabolic parameters related to restenosis in patients with dysglycemia. Seventy consecutive patients (77 lesions) selected according to inclusion and exclusion criteria were evaluated by the oral glucose tolerance test and the determination of insulinemia after a successful percutaneous coronary intervention (PCI) with a bare-metal stent. The degree of insulin resistance was calculated by the homeostasis model assessment of insulin resistance (HOMA-IR). Six-month IVUS and angiogram follow-up were performed. Thirty-nine patients (55.7 percent) had dysglycemia. The restenosis rate in the dysglycemic group was 37.2 vs 23.5 percent in the euglycemic group (P = 0.299). The predictors of restenosis using bivariate analysis were reference vessel diameter (RVD): £2.93 mm (RR = 0.54; 95 percentCI = 0.05-0.78; P = 0.048), stent area (SA): <8.91 mm² (RR = 0.66; 95 percentCI = 0.24-0.85; P = 0.006), stent volume (SV): <119.75 mm³ (RR = 0.74; 95 percentCI = 0.38-0.89; P = 0.0005), HOMA-IR: >2.063 (RR = 0.44; 95 percentCI = 0.14-0.64; P = 0.027), and fasting plasma glucose (FPG): ≤108.8 mg/dL (RR = 0.53; 95 percentCI = 0.13-0.75; P = 0.046). SV was an independent predictor of restenosis by multivariable analysis. Dysglycemia is a common clinical condition in patients submitted to PCI. The degree of insulin resistance, FPG, RVD, SA, and SV were correlated with restenosis. SV was inversely correlated with an independent predictor of restenosis in patients treated with a bare-metal stent.

Intervencionismo en oclusiones crónicas: evaluación de la efectividad cruce de distintas guías y balones según complejidad / Percutaneous coronary interventions in chronic coronary occlusions: effectiveness of different guides and balloons according to complexity of total coronary artery occlusion

Antecedentes: El intervencionismo en las oclusiones totales crónicas (OTC) requiere técnicas complejas y el éxito es poco predecible. Es útil identificar la efectividad de las guías de cruce y del balón para el intervencionismo en distintos niveles de complejidad de OTC. Objetivos: Evaluar la efectividad de cruce de distintas guías y balones en el tratamiento de OTC. Métodos: Se revisa en forma retrospectiva la efectividad de distintos tipos de guías y balones de cruce utilizados en intervencionismo de OTC efectuados entre agosto de 2007 y agosto de 2009. Se define "efectividad" como la capacidad de avanzar y cruzar la oclusión crónica con la guía y el balón, ambas necesarias para efectuar la angioplastia de la OTC. Se agrupan los resultados según el nivel de complejidad de la OTC de acuerdo a score propio, distinguiendo entre OTC simples, complejas y de alta complejidad. Resultado: En el período estudiado se revisan 90 OTC. Se utilizan 148 guías (1,6 guía/proc.) y se utilizan 92 balones en 76 procedimiento que logran paso efectivo de guía. (1,2 bal/proc). Se realiza una tabla con la tasa de efectividad de distintas guías y balones de cruce. Destaca la utilidad de guía PT2 en lesiones simples y complejas, como la utilidad de la guía Miracle 6 en OTC de alta complejidad. Conclusiones: En OTC se obtiene un éxito de 67 por ciento en nuestro medio, con mayor efectividad de la guía PT2 en lesiones simples y complejas y de Miracle 6 en lesiones de alta complejidad. En cuanto a balones se obtiene mayor efectividad en los tipo Maverick, Mercury y Voyaguer de 1,5 mm en lesiones simples y complejas, como del Balón Maverick de 1,5 mm en lesiones de alta complejidad. Es de gran utilidad un registro de la efectividad de balones y guías en el tratamiento de OTC, lo que permite al intervencionista una adecuada elección del material con el consecuente ahorro de tiempo y mayor efectividad del procedimiento.

Background.: PCI in chronic coronary occlusions requires complex techniques and is associated to less predictable results. It is important to evaluate the effectiveness of different guides and balloons in PCI for total coronary occlusion (TCO). Aim: To evaluate the effectiveness of different guides and balloons in the treatment of TCO. Methods: A retrospective review of the effectiveness of different guides and balloons in the treatment of TCO performed from 2007 to 2009 was carried out Effectiveness was defined as the ability to traverse the occlusion with the guide and the balloon. The analysis was performed according to groups defined by the complexity of the TCO as assessed by a locally developed score. Occlusions were classified as simple, complex or highly complex. Results: 90 procedures were analyzed 148 guides were utilized (mean of 1.6 per procedure) and 92 balloons were used in 76 cases were the guide successfully crossed the occlusion. The PT2 guide was effective for simple and complex lesions, whereas de Miracle 6 guide was effective in the treatment of highly complex lesions. Regarding balloons, the Maverick, Mercury and Voyageur 1.5 mm were satisfactory in simple and complex lesions, while the Maverick 1.5mm was more effective in highly complex lesions Conclusion: TCO was successfully treated by PCI in 67 percent of cases. PT2 guides and all types of balloons were effective for treatment of simple and complex lesions. In contrast, the Miracle 6 guide and the Maverick 1.5 balloon were more effective in highly complex lesions. These findings may be useful to help de proper selection of angioplasty materials when treating.

Tratamento de lesões calcificadas com uso do dispositivo Tornus: relato de dois casos / Treatment of calcified lesions with the tornus device: report of two cases

Apresenta-se neste relato o tratamento bem-sucedido de dois pacientes com lesões coronárias complexas, calcificadas, sendo uma delas uma oclusão total crônica, na qual foi utilizado um novo dispositivo para facilitar o procedimento percutâneo.

We describe two complex cases of calcified lesions, one of which a total chronic occlusion, that were successfully treated with a new device that facilitates the percutaneous procedure.

Resultados imediatos e tardios do implante de stents farmacológicos para o tratamento de bifurcações: comparação entre as estratégias de um stent versus dois stents / Immediate and Late Results of Drug-Eluting Stent Implantation for the Treatment of Coronary Bifurcation Lesions: Comparison Between One-Stent and Two-Stent Strategies

Fundamentos: Os stents farmacológicos reduziram a necessidade de nova revascularização nas lesões bifurcadas. Entretanto, o seguimento tardio e a estratégia mais adequada (um stent vs. dois stents) não estão bem estabelecidos. Método: No período de junho de 2002 a dezembro de 2006, 156 pacientes consecutivos com lesões envolvendo bifurcações foram tratados com implante de stents farmacológicos. Comparou-se a taxa de eventos cardíacos adversos maiores (ECAM) combinados ­ óbito, infarto e revascularização do vaso-alvo (RVA) ­ e a incidência de trombose do stent conforme a estratégia (um stent: ramo principal vs. dois stents: ramos principal e lateral). Resultados: A média das idades foi de 64 ± 12 anos, 75,6% eram do sexo masculino e 28,8%, diabéticos. O seguimento médio foi de 2,4 ± 1,3 anos. Utilizou-se a estratégia com um stent em 67,3% dos pacientes. Bifurcações verdadeiras ocorreram em 64,7% dos casos. A estratégia de dois stents foi adotada em 32,7% dos casos (crush: 14,7%; cullote: 3,2%; T-stent: 10,3%; simultaneous kissing stent: 3,8%; V-stent: 0,6%). Kissing balloon final foi utilizado em 85,9% dos casos. A sobrevida livre de ECAM estimada foi de 95% na estratégia com um stent vs. 86% com dois stents (teste do log-rank, p = 0,03). A análise multivariada identificou o uso de dois stents como único preditor independente de ECAM (OR: 2,82; IC 95%: 1,04- 7,68; p = 0,04). A taxa de trombose no emprego de um stent em comparação com dois stents foi de 1,9% vs. 3,9% (p = 0,6)...

Background: Drug-eluting stents (DES) have reduced the need for repeat revascularization in coronary bifurcation lesions. However, late follow-up and the most adequate strategy (one stent vs. two stents) have not been well established. Methods: From June 2002 to December 2006, 156 consecutive patients underwent drug-eluting stent implantation to treat coronary bifurcation lesions. The rates of major adverse cardiac events (MACE) ­ death, myocardial infarction, and target-vessel revascularization (TVR) ­ and stent thrombosis were compared according to the strategy adopted (one-stent: main branch vs. twostents: main branch and side branch). Results: The mean age of the group was 64 ± 12 years; 75.6% of the patients were men and 28.8% were diabetic. The mean follow-up duration was 2.4 ± 1.3 years. The one-stent strategy was used in 67.3% of the patients. 64.7% of the lesions treated were true bifurcations. The two-stent techniques strategy were used in 32.7% of the cases (crush: 14.7%; cullote: 3.2%; T-stenting: 10.3%; simultaneous kissing stent: 3.8%; V-stenting: 0.6%). Final kissing balloon inflation was used in 85.9% of the cases. The combined event-free survivalwas estimated to be 95% with the one-stent strategy vs. 86% with the two-stent strategy (p Log Rank = 0.03). Multivariate analysis identified the two-stent strategy as the only independent predictor of MACE (OR: 2.82; IC 95%: 1.04-7.68; p = 0.04). Stent thrombosis rates using one stent was 1.9% vs. 3.9% using two stents; p = 0.6)...

Tornus catheter facilitated recanalization of chronic total occlusions--another niche device for a difficult lesion subset.

One of the last frontiers facing interventionalists is the treatment of chronic total occlusions. Chronic total occlusions (CTO) are present in about one-third of all diagnostic coronary angiograms. Recanalizations of these CTOs have demonstrated a trend towards lower mortality. Unfortunately, use of standard angioplasty equipment has only resulted in a 50-60% success rate.5,6,7 Several recently developed guidewires have increased success rates to 79-90%. Further success in CTO revascularization has been improved by use of novel techniques such as crossing the lesion in a retrograde fashion from collateral vessels. Niche devices such as the Frontrunner CTO catheter (Lumend Inc., Johnson and Johnson, Picataway, NJ) have also facilitated in successful treatment of CTOs. Unfortunately, none of these developments address the issue of deliverability of angioplasty balloons and stents. A newly developed device, the Tornus catheter (Asahi Intech; Abbot Vascular, Redwood City, CA), plays a niche role in the recanalization of this lesion subset. The following contains two case reports which highlight successful revascularization of CTOs with utilization of this new catheter.

Angioplastía primaria en el tratamiento de la oclusión aguda del tronco de la arteria coronaria izquierda / Primary angioplasty in the treatment of acute occlusion of the left coronary artery branch

La oclusión total del tronco coronario común izquierdo (TCI) es un hallazgo infrecuente en la cateterización cardiaca y más aún en pacientes con IAM con SDST, en este último contexto se presenta clínicamente con shock cardiogénico, arritmias malignas y/o muerte. Si bien en el paciente estable la cirugía continúa siendo la primera opción terapéutica1, en las oclusiones agudas dado el riesgo vital y la necesidad de reperfusión lo más precoz posible, la angioplastia primaria se considera como una opción real de salvataje. A continuación presentamos un caso clínico de un paciente con infarto agudo al miocardio con oclusión aguda del TCI tratado con angioplastía primaria.

The total occlusion of the left main coronary artery is a rare finding in the cardiac catheterization and even more so in patients with Acute Myocardial Infarction with ST-segment elevation. These patients presented clinically with cardiogenic shock, malignant arrhythmia and/or death. While in the patient is stable, the surgery remains the first choice therapy (1), but in acute occlusion given the risk to life and the need for the earliest possible reperfusion, primary angioplasty is considered as a real option bailout. The following is a case of a patient with acute myocardial infarction and acute occlusion of left main coronary artery treated with primary angioplasty is considered as real option bailout. The following is case of a patient with acute myocardial infarction and acute occlusion of left main coronary artery treated with primary angioplasty.

Evaluation of stentangioplasty in university cardiac center.

In this ongoing prospective study conducted in University Cardiac Center, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from July 2004 to January 2006. Fifty (50) patients (mean age 56+/-7.2 years) underwent stentangioplasty were evaluated. The study group of 50 patients consisted of 42 (84%) men and 08 (16%) women. The aim of this study was to evaluate in-hospital success, failure and complications during the procedures. About risk factors 19(38%) had hypertension, 13(26%) were smoker, 11(22%) suffered from diabetes mellitus, 05(10%) had family history of ischaemic heart disease. Average left ventricular ejection fraction was 54+/-7. Target vessel percutaneous coronary angioplasty (PTCA) were done in 61 vessel, intracoronary stent implanted in 58 vessels, direct stenting were done in 35 cases, failed PTCA were in 03(6%) cases and two had dissection. The native vessels had a mean reference diameter of 2.91 mm and their luminal diameter increased significantly after percutaneous coronary intervention (PCI). All the patients were discharged by one to three days of the procedure with improvement of their clinical condition. In conclusion, intracoronary stent deployment in coronary artery stenosis following balloon angioplasty is a valid and beneficial strategy with good in-hospital results.

Lesões coronarianas de bifurcação: classificação, estratégias de tratamento e perspectivas: revisão / Coronary bifurcation lesions: classification, strategies of treatment and perspectives: review

A ocorrência de obstruções coronarianas que envolvem ramos laterais, com maior ou menor risco de oclusão, não é um evento raro. O tratamento percutâneo destas lesões de bifurcação tem sido um desafio para a cardiologia intervencionista. A apresentação extremamente variada, seja pela disposição dos ramos, propiciou a descrição de várias classificações. Ainda com a utilização de angioplastia coronária com cateter-balão, muitas técnicas foram escritas. Todas apresentavam resultados tardios poucos satisfatórios. Com o aparecimento dos stents na prática clínica, outras estratégias foram descritas, com a utilização de um e dois stents. No entanto, as taxas de revascularização da lesão-alvo permaneceram altas. O uso de stents com eluição...

Trombose coronariana tardia secundária a implante de stent com paclitaxel sem reestenose dos stents convencionais / Late coronary thrombosis secondary to implantation of paclitaxel-eluting stent without restenosis of conventional stents

Homem de 39 anos com angina pós-infarto. Coronariografia demonstrou: obstrução total proximal da artéria coronária direita (ACD), lesões obstrutivas de 95 por cento na artéria descendente anterior (ADA), 80 por cento no 2° ramo marginal esquerdo (ME) e 95 por cento na artéria circunflexa (ACX). O paciente foi submetido a implante de stent TAXUS 3,0 x 24 mm e stent EXPRESS 2,75 x 24 mm nos terços proximal e distal da ACD, respectivamente, e stent INFINNIUM 3,0 x 24 mm na ADA com sucesso. Após 7 meses, apresentou IAM anterior por trombose do stent INFINNIUM e reestenose do stent TAXUS, sem perda de resultado nos stents convencionais.

A male 39 year-old patient with post-infarction angina. The coronary angiography showed total proximal obstruction of right coronary artery (RCA), obstructive lesions of 95 percent of the anterior descending artery (ADA), 80 percent of the second left marginal branch (LM2), and 95 percent of the circumflex artery (CXA). The patient was successfully implanted with a Taxus 3.0 x 24 mm stent and an Express 2.75 x 24 mm stent in the proximal and distal thirds of the RCA, respectively, and with an Infinnium 3.0 x 24 mm stent in the ADA. After seven months, the patient had an anterior acute myocardial infarct (AMI) due to thrombosis of the Infinnium stent and restenosis of the Taxus stent, with no loss of results in the conventional stents.

Resultados clínicos inmediatos y alejados del implante de stents metálicos no recubiertos: ¿Se justifica un reemplazo total por los stents liberadores de drogas? / Acute and long-term clinical results of bare metal coronary stenting

Background: Since the introduction of stents in 1994, improved clinical results have boosted the development of coronary angioplasty in Chile. Drug eluting stents, that have a reduced rate of restenosis, are being increasingly used. Aim: To assess the acute and long-term results of bare metal stent implantation. Patients and Methods: Acute and long-term clinical, procedural and angiographic results were assessed in non acute myocardial infarction patients undergoing coronary stent implantation between August 1996 and December 2003. Results: During the study period, 932 patients aged 30 to 87 years (194 women) had at íeast one stent implanted. Twenty two percent were diabetic, 33 percent had recent myocardial infarction, 53 percent unstable angina and 22 percent stable angina. Angiographic and clinical success were 99.6 percent and 98.2 percent, respectively. In hospital death was 0.5 percent. During a mean follow-up of 19.1 months, all cause mortality was 3.9 percent, cardiac death 1.9 percent and survival free of major cardiac ischemic events was 85.3 percent. Only 6.4 percent of lesions underwent target vessel revascularization (TVR). Independent predictors of TVR were previous surgery, íeft anterior descending artery, small post stent minimum luminal diameter. Ostial location, in-stent restenosis, and younger age were non significant predictors. Conclusions: Acute and long-term results of bare metal stents in this population were excellent. An intriguingly low rate of TVR was seen. Selective bare metal stenting should continue in lesions and patients with a low risk of clinical restenosis.

Angioplastia con stents liberadores de rapamicina en diabéticos tipo 2: Experiencia del Hospital DIPRECA / Angioplasty stenting with Sirolimus (Rapamycin) eluting stents in type 2 diabetic patients

Background: Drug-eluting stents have been developed to reduce the rates of restenosis after coronary angioplasty. Several studies have demonstrated that rapamycin eluting stents are reliable and effective. Aim: To report the experience in our Health Centre with rapamycin-eluting stents. Patients and methods: Forty two stents with rapamicine were implanted to 32 diabetic patients, between June 2002 and December 2004. After the procedure, subjects were clinically followed-up for an average period of 19.9+9.9 months, evaluating functional capacity, angina pectoris, dyspnea, need for hospital admission, acute coronary events and cardiac death. In those subjects clinically suspected to have restenosis, a coronary angiography was performed. Results: Twenty-nine subjects (90.6 percent) remained asymptomatic, two subjects (6.3 percent) developed angina pectoris but restenosis was ruled out, and one subject (3.1 percent) died. Conclusions: The use of rapamycin-eluting stents in these patients was safe and successful with no evidence of clinic restenosis. These positive results are similar to those reported in the Diabetes Study.

Newer stents: looking at the horizon.

More challenging and complex lesions are being treated with drug:eluting stents. This review examines advances in some of the commercially available stents together with important new stents under development. These include stents with novel platforms for drug elution, biodegradable, and bioabsorbable polymer/stents and stents dedicated to specific lesions. It also discusses novel pharmacological agents aimed at targeting inflammation and restenosis together with bio-engineered stents and combination drug therapies.