Revascularização da descendente anterior proximal com stents revestidos por fármacos / Proximal left anterior descending coronary artery revascularization with drug-eluting stents

OBJETIVO: Avaliar o prognóstico clínico dos doentes coronários submetidos a revascularização percutânea com implantação de stents revestidos com fármacos na descendente anterior proximal. MÉTODOS: Cento e setenta doentes consecutivos, com idade média de 65 anos, 49 (29 por cento) mulheres, receberam implante de pelo menos um stent revestido com fármaco, no nosso centro. O número total de stents revestidos com fármaco implantados foi 189, dos quais 115 (61 por cento) de sirolimus (CYPHER®) e 74 (39 por cento) de paclitaxel (TAXUS®). Em 100 (60 por cento) dos casos, estava presente doença coronário multivaso. Em 61 (36 por cento) dos doentes tratou-se outro segmento coronário para além da descendente anterior proximal. Efetuou-se um seguimento clínico durante um tempo médio de 11 ± 5 meses e controle angiográfico entre os seis e os nove meses. Obteve-se um endpoint final composto por morte, infarto agudo do miocárdio e pela necessidade de reintervenção sobre a descendente anterior. Analisou-se secundariamente a ocorrência de reestenose, a necessidade de reintervenção sobre o segmento proximal da descendente anterior e a trombose de stent. RESULTADOS: O procedimento teve êxito angiográfico imediato em todos os doentes. Registraram-se duas mortes, dois infartos agudos do miocárdio, e duas reintervenções coronárias percutâneas por trombose de stent no período intra-hospitalar. Aos seis meses de seguimento, observou-se mais uma morte cardíaca e identificaram-se três infartos do miocárdio; houve necessidade de três novos procedimentos de revascularização. Até ao final do seguimento, verificaram-se mais três mortes, três infartos do miocárdio e oito revascularizações da descendente anterior, duas delas por cirurgia. A sobrevivência livre de eventos cardíacos adversos maior foi de 91 por cento. A mortalidade cardíaca foi de 3 por cento. A reestenose binária no segmento proximal da descendente anterior foi de 4,1 por cento. A sobrevivência livre...

OBJECTIVE: To assess the clinical prognosis of patients with coronary artery diseases undergoing percutaneous revascularization with drug-eluting stent implantation in the proximal left anterior descending coronary artery. METHODS: One hundred and seventy consecutive patients with mean age of 65 years, 49 of them females (29 percent), undergoing implantation of at least one drug-eluting stent in our medical center. The total number of drug-eluting stents implanted was 189, of which 115 (61 percent) were sirolimus-eluting (CYPHER TM) and 74 (39 percent) were paclitaxel-eluting stents (TAXUS TM). In 100 (60 percent) of the cases, multivessel coronary artery disease was present. In 61 (36 percent) patients another coronary artery segment was treated in addition to the proximal left anterior descending coronary artery. The mean clinical follow-up period was 11 ± 5 months, and angiographic controls were performed between 6 and 9 months. The final endpoint was a composite of death, acute myocardial infarction and need for reintervention on the anterior descending. The secondary endpoint included the occurrence of restenosis, need for reintervention on the proximal segment of the left anterior descending and stent thrombosis. RESULTS: The procedure achieved immediate angiographic success in all patients. Two deaths, two acute myocardial infarctions, and two percutaneous coronary reinterventions due to stent thrombosis were recorded during in-hospital stay. At the sixth month of follow-up, an additional cardiac death and three myocardial infarctions were observed; three repeat revascularization procedures were required. Up to the end of the follow-up, three additional deaths, three myocardial infarctions and eight revascularization procedures of the anterior descending, two of them surgical, were verified. Survival free from major adverse cardiac events was 91 percent. Cardiac mortality was 3 percent. Binary restenosis in the proximal segment...

Compromiso de vasos secundarios durante la implantación directa de stent coronario: Incidencia y factores relacionados / Side branch occlusion during direct stent implantation: Incidence and related factors

Objetivo: El objetivo fue evaluar el grado de compromiso de las ramas que son enjauladas durante la implantación directa de stent. Pacientes y métodos: Se estudiaron 56 pacientes en los que se implantó al menos un stent coronario (58 stents) sin dilatación previa con balón y en los que se enjauló alguna rama secundaria. Se evaluó la tasa de pérdida de la rama, el efecto de la implantación del stent sobre el flujo de esta rama y los factores relacionados con estos hechos. Resultados: El vaso principal fue la descendente anterior en el 63%, la circunfleja en el 21%, la coronaria derecha en el 14% y el tronco principal de la coronaria izquierda en un caso. Se obtuvo éxito angiográfico sobre el vaso principal en todos los casos. Antes del procedimiento, el flujo a nivel de la rama secundaria era TIMI grado 3, 2 y 0 en 55 (95%), 2 (3%) y un caso (2%), respectivamente. Tras la implantación del stent, el flujo era TIMI grado 3, 2, 1 y 0 en 50 (86%), 1 (2%), 2 (3%) y 5 (9%) casos, respectivamente (p = 0.204). La incidencia de pérdida de la rama fue 12% (7/58); en un caso, se intentó con éxito recanalizar y dilatar ésta a través de los struts del stent, por lo que la tasa de pérdida de rama final fue 10% (6/ 58). Las ramas que se ocluyeron tenían un mayor grado de estenosis en el origen antes de la implantación del stent (30.2 ± 31.3% vs 16.8 ± 11.1%, p = 0.028). En los pacientes que se reevaluaron angiográficamente, a los 6.2 ±1.9 meses, el 50% de las ramas que se habían ocluido se encontraban permeables, y el 88% de las que no se comprometieron seguían permeables. Conclusiones: La tasa de oclusión de las ramas con la implantación directa de stent fue 12% en nuestra serie, cifra similar a la que ocurre con la implantación de stent tras dilatación con balón. Por tanto, la existencia de ramas localizadas en el segmento en el que va a implantarse el stent no tiene por qué condicionar la decisión o no de realizar una dilatación previa con balón.

Aim: The aim of the study was to evaluate the compromise of side branches when jailed by a coronary stent implanted without balloon predilation. Patients and methods: 56 patients in which at least a coronary stent was implanted without balloon predilation and covering a side brach (58 stents, 1.04 ± 0.19 per patient) were studied. The effect of direct coronary stent implantation over side branch flow, as well as the characteristics associated were studied. Results: The main vessel was left anterior descending in 63%, left circumflex in 21%, right coronary in 14%, and left main in one case. An angiographic successful result in the main vessel was obtained in all cases. Coronary flow was TIMI 3, 2, 1, and 0 in 95%, 3%, 0%, and 2% before the procedure, in comparison with 86%, 2%, 3%, and 9% after stent implantation (p = 0.204). The incidence of side branch occlusion was 12% (7/58). In one case, the side branch was dilated across the stent struts, and thus the rate of side branch loss at the end of the procedure was 10% (6/58). In cases of side branch occlusion, there was a more severe stenosis at its origin before stent implantation (30.2 ± 31.3% vs 16.8± 11.1%, p = 0.028). Fifty percent of side branches occluded after direct coronary stent implantation and angiographically reevaluated at follow-up became patent, and 88% of side branches not affected after stent implantation remained patent at 6.2 ± 1.9 months. Conclusion: The rate of side branch occlusion after direct stent implantation in our series was 12%, that is not different from that reported for conventional stent implantation. Thus, the decision of using direct or conventional coronary stenting should not be conditioned by the presence of side branches arising from the target lesion.

Multiple congenital coronary artery fistulae draining into the left ventrice / Físulas coronariias congénitas múltiples drenando el ventrículo izquierdo

Coronary artery fistula between a coronary artery and a cardiac chamber is a rare condition, especially when multiple fistulas communicate with the left ventricle. Herein we report a case of an elderly woman with multiple diffuse coronary artery-left ventricular fistulas diagnosed by angiography. Since the coronary artery-cardiac chamber communications were multiple and diffuse neither surgery nor transcatheter coil occlusion was considered in this case.

Las fístulas de las arterias coronarias que drenan a las cavidades cardíacas son una anomalía infrecuente, especialmente cuando son múltiples y drenan hacia el ventrículo izquierdo. Presentamos el caso de una mujer octogenaria con múltiples fístulas difusas que se originan de la coronaria izquierda y que drenan al ventrículo izquierdo. El hecho de que fuesen múltiples y difusas imposibilitó una intervención quirúrgica o percutánea como se recomienda en estos casos. (Arch Cardiol Mex 2004; 74:45-48).

Reconocimiento angiográfico de la comunicación interauricular / Angiographic recognition of atrial septal defect

Dado el desarrollo de la ecocardiografía y de la ecocardiografía Doppler, el diagnóstico angiográfico de los defectos interauriculares no es imprescindible para el correcto manejo de estos pacientes. Sin embargo se hace esencial cuando los defectos septales están acompañados de malformaciones cardíacas más complejas. Las comunicaciones interauriculares pueden ser divididas en: a) Defectos relacionados con la porción de entrada de la cámara auricular. b) Defectos de la porción media del septo (fosa oval). c) Defectos relacionados con la porción de salida de las cámaras auriculares, en la unión atrioventricular. Se consideran las características anatómicas, la proyecciones a utilizar y las características angiocardiográficas y ecocardiográficas para reconocer y diferenciar las diversas comunicaciones interauriculares