Implantação de stent na bifurcação do tronco da coronária esquerda: uma análise em 2023 / Left main bifurcation stenting: a 2023 appraisal

Por várias décadas, a revascularização do miocárdio foi considerada o tratamento padrão-ouro de lesões não protegidas do tronco da coronária esquerda. No entanto, a acessibilidade anatômica e o grande calibre dos vasos tornam as lesões de tronco uma opção atraente para a intervenção coronária percutânea. A aplicação dessa intervenção nesse cenário foi expandida ainda mais como resultado da introdução de novos stents farmacológicos, com rápidos avanços em técnicas, dispositivos e farmacoterapias adjuvantes. As evidências atuais têm demonstrado que pacientes com complexidade coronariana baixa ou intermediária têm desfechos similares com a intervenção coronária percutânea ou a revascularização cirúrgica do miocárdio por até 10 anos. O tratamento das lesões da bifurcação do tronco da coronária esquerda continua tecnicamente complexo, apesar dos recentes avanços. A abordagem provisional é a estratégia padrão na maioria dos tipos de lesões da bifurcação do tronco da coronária esquerda. No entanto, algumas lesões complexas da bifurcação do tronco da coronária esquerda justificariam uma técnica eletiva com implante de dois stents. A abordagem integrada, que incorpora técnicas dedicadas, uma avaliação fisiológica e anatômica adjuvante e agentes farmacológicos, é fundamental para abordar com sucesso esse desafio ímpar e melhorar os desfechos clínicos.

For several decades coronary bypass grafting has been considered the gold standard treatment for unprotected left main coronary artery lesions. However, the anatomic accessibility and the large caliber of the vessel render the percutaneous coronary intervention a very attractive treatment option for left main coronary artery lesions. The use of percutaneous coronary intervention in this subset of lesions has been further expanded as a result of the introduction of newer drug-eluting stents along with rapid advancements in techniques, devices, and adjunctive pharmacotherapies. The current evidence has demonstrated that patients with low or intermediate coronary complexity treated with percutaneous coronary intervention or coronary bypass grafting have comparable outcomes, for up to 10 years. Treatment of left main bifurcation lesions remains technically demanding despite recent developments. The provisional approach is the default strategy in most types of left main bifurcation lesions. However, a few complex left main bifurcation lesions would warrant an elective two-stent technique. An integrated approach incorporating custom- tailored techniques, adjunctive physiological and morphologic evaluation, and pharmacologic agents is critical to tackle this unique challenge and improve clinical outcomes.

Complicações em Serviços de Hemodinâmica ­ como agir / Complications in Cath Lab ­ how to bail out

Vários fatores, incluindo intervenções terapêuticas aprimoradas e tecnologias avançadas, levaram a melhores desfechos clínicos nas intervenções coronárias percutâneas complexas. No entanto, ainda podem ocorrer complicações capazes de impactar negativamente na sobrevida do paciente e nos custos de saúde. O risco dessas complicações pode ser reduzido, por meio de operadores experientes e procedimentos preventivos. Este artigo discute uma série de casos de cinco pacientes com problemas específicos relacionados aos procedimentos, como perfuração coronária, dissecções, fechamento abrupto das coronárias e fenômeno de no-reflow.

Various factors, including improved therapeutic interventions and advanced technologies, have led to better clinical outcomes for complex percutaneous coronary interventions. However, complications can still occur and have a negative impact on patient survival and healthcare costs. The risk of these complications can be reduced through experienced operators and preventative procedures. This article discusses a case series of five patients with specific periprocedural issues, such as coronary perforation, dissections, abrupt closure of the coronaries, and no-reflow phenomenon.

Doença coronariana em jovens: novas formas de detecção, prevenção e tratamento / Coronary heart disease in young individuals: novel ways to detect, prevent and treat

Apesar dos grandes avanços nas estratégias de manejo e prevenção da aterosclerose, a prevalência da doença arterial coronariana aumenta em todo o mundo, tendo início em idade precoce. As doenças cardiovasculares em adultos jovens caracterizam-se como um grupo heterogêneo de doenças que ocorrem por causas congênitas ou adquiridas. Múltiplos fatores de risco, como dislipidemia, doença coronária prematura, diabetes melito e tabagismo, potencializam o risco do paciente para a coronariopatia precoce. A avaliação precoce de pacientes com doença arterial coronariana pode ser feita por meio de vários métodos de imagem não invasivos, que facilitam a seleção precoce de condutas preventivas e terapêuticas efetivas para manejo da doença arterial coronariana; no entanto, ela está associada a várias dificuldades, devido às limitações dos escores de risco e à sensibilidade limitada de vários métodos de rastreamento. Neste manuscrito, discutimos sobre fisiopatologia, fatores de risco, métodos de imagem invasivos e não invasivos e várias estratégias de manejo na prevenção precoce da doença coronariana em adultos jovens e, mais importante, os rumos futuros e a prevenção de doenças e da morte súbita cardíaca.

In spite of major advancements in the management and prevention strategies of atherosclerosis, the prevalence of coronary artery disease has risen worldwide, and might start at an early age. Cardiovascular diseases among young adults are characterized as a heterogeneous group of disorders due to congenital or acquired causes. Multiple risk factors, such as dyslipidemia, premature coronary heart disease, diabetes mellitus and cigarette smoking potentiate the patient's risk for early coronary heart disease. Early assessment of patients with coronary artery disease can be performed using various non-invasive imaging methods, which facilitate early selection of effective and preventative therapies for coronary artery disease management; however, it is associated with several challenges due to limitations in risk calculators, and limited sensitivity of various screening methods. In this manuscript, we will discuss about pathophysiology, risk factors, invasive and non- invasive imaging methods, and various management strategies for the early prevention of coronary heart disease in young adults and, importantly, the future directions and preventing disease and sudden cardiac death.

Drug-coated balloon in the treatment of coronary bifurcation lesions: A hope or hype?

When compared to non-bifurcation lesions, percutaneous coronary intervention in coronary bifurcation lesions is technically demanding and has historically been limited by lower procedural success rates and inferior clinical results. Following the development of drug-eluting stents, dramatically better results have been demonstrated. In most of the bifurcation lesions, the provisional technique of implanting a single stent in the main branch (MB) remains the default approach. However, some cases require more complex two-stent techniques which carry the risk of side branch (SB) restenosis. The concept of leaving no permanent implant behind is appealing because of the complexity of bifurcation anatomy with significant size mismatch between proximal and distal MB which may drive rates of in-stent restenosis and the potential impact of MB stenting affecting SB coronary flow dynamics. With the perspective of leaving lower metallic burden, a drug-coated balloon (DCB) has been utilized to treat bifurcations in both the MB and SB. The author gives an overview of the existing state of knowledge and prospects for the future for using DCB to treat bifurcation lesions.

A Study on the Role of Urinary Congophilia in Early Detection of Preeclampsia

Introduction?Preeclampsia and eclampsia are important causes of maternal morbidity. Preeclapmtic women secrete misfolded proteins in the urine. Buhimschi et al had developed a new test for diagnosis of preeclampsia. This test is based on staining of misfolded protein with Congo red dye. Misfolded proteins are derived from syncytiotrophoblast microparticles (STBMs). These STBM are membrane bound vesicles and contain misfolded proteins. In preeclampsia, glomeruli of kidneys are disrupted and these damaged protein reach the urine. Aim and Objective?This study aimed to investigate the role of urinary congophilia in early prediction of preeclampsia. Materials and Methods?This test was done in 250 pregnant women attending the Gynaecological Outpatient Department. Urine sample of early morning was taken and test was done in the Department of Biochemistry. The included pregnant women were of gestational age between 14 and 18 weeks. The staining of urine with Congo red dye was done and washed with methanol. The retention of dye was interpreted with naked eye. The more retention of dye, the more chances of developing preeclampsia later. The patients were followed-up till delivery. The patents who developed preeclampsia later part of pregnancy were recorded. Mean arterial pressure (MAP) and past history and body mass index were also recorded. Results?Out of 250 patients, 30 developed preeclampsia later. A total of 34 patients were having positive urinary congophilia and only 20 patients developed preeclampsia later. MAP more than 90?mm Hg is abnormal but 66.7% of patients who developed preeclampsia had MAP >90?mm Hg. In 16.7% of patients, who developed preeclampsia later, had positive past history of hypertension. In 66.7% of patients, who were positive for urinary congophilia, later developed preeclampsia. Conclusion?Preeclampsia and eclampsia are important causes of maternal mortality and morbidity. So, early detection can prevent complications and timely management. Urinary congophilia is one of such test which can help in early prediction of preeclampsia. If it is combined with past maternal history and MAP, it gives more good results. The detection rate is much higher if signs and symptoms of preeclampsia are noticed timely.

Tratamento de complicações durante intervenção coronariana percutânea: avaliação da situação atual / Management of complications during percutaneous coronary intervention: a current appraisal

Tecnologias mais avançadas, drogas melhores e profissionais mais experientes contribuíram para desfechos otimizados das intervenções coronarianas percutâneas complexas. As complicações com impacto significativo na sobrevida do paciente e alto custo para o sistema de saúde não foram totalmente eliminadas pelos procedimentos modernos de intervenções coronarianas percutâneas. Os procedimentos preventivos e a experiência do operador são as únicas formas de se evitarem os efeitos colaterais graves das intervenções coronarianas percutâneas. As dissecções, o fechamento abrupto da artéria, a perfuração coronariana, o non-reflow, a embolia gasosa, a deformação do stent, a embolização do dispositivo e o aprisionamento da ogiva de aterectomia rotacional são algumas das complicações abordadas neste artigo.

More advanced technology, better drugs and more experienced operators have contributed to improved complex percutaneous coronary intervention outcomes. Complications with significant impact on patient survival and healthcare costs have not been completely eliminated by modern percutaneous coronary intervention procedures. Professional expertise and consistent preventive procedures are the only ways to avoid severe side effects of percutaneous coronary intervention. Dissections, abrupt arterial closure, coronary perforation, no-reflow, air embolism, stent deformation, device embolization, and rotating atherectomy burr entrapment are some of the periprocedural complications covered in this article.

Inteligência artificial na fisiologia coronária: onde estamos? / Artificial intelligence in coronary physiology: where do we stand?

O uso da fisiologia coronariana invasiva na seleção de indivíduos para revascularização coronariana foi estabelecido nas orientações atuais para manejo da doença arterial coronariana estável. Em comparação com a angiografia isolada, a fisiologia coronariana provou melhorar os resultados clínicos e a relação custo-efetividade no processo de revascularização. Ensaios controlados randomizados, no entanto, questionaram a eficácia do teste de isquemia na seleção de indivíduos para revascularização. Após uma intervenção coronária percutânea com sucesso angiográfico, 20 a 40% dos pacientes apresentaram angina persistente ou recorrente. A inteligência artificial é definida como o uso de vários algoritmos e conceitos computacionais para realizar tarefas complexas de maneira eficiente. Pode ser classificada em dois tipos: abordagens não supervisionadas e supervisionadas. O aprendizado supervisionado é usado principalmente nas tarefas de regressão e classificação, e nele é realizado um mapeamento otimizado entre variáveis de saída e entrada pareadas para executar as tarefas. Em contraste com isso, o aprendizado não supervisionado funciona de maneira diferente. Nesse aprendizado, os dados das variáveis de saída não estão disponíveis, e outros clusters e relações entre os dados de entrada são descobertos, usando-se vários algoritmos. Para se adquirir uma representação mais abstrata dos dados, a tecnologia de aprendizado profundo que utiliza as redes neurais multicamadas domina o aprendizado artificial atualmente.

The use of invasive coronary physiology to select individuals for coronary revascularization has been established in current guidelines for the management of stable coronary artery disease. Compared to angiography alone, coronary physiology has been proven to improve clinical outcomes and cost-effectiveness in the revascularization process. Randomized controlled trials, however, have questioned the efficacy of ischemia testing in selecting individuals for revascularization. After an angiographically successful percutaneous coronary intervention, 20 to 40% of patients experienced persistent or recurrent angina. Artificial intelligence is defined as the usage of various algorithms and computational concepts to perform the complex tasks in an efficient manner. It can be classified into two types: unsupervised and supervised approaches. Supervised learning is majorly used for the regression and classification tasks, and in this optimized mapping between output variables and paired input is carried out to perform the tasks. In contrast to this, unsupervised learning works in the different manner. In unsupervised learning, output variables data is not available and further clusters and relations between input data are found out by using the various algorithms. To acquire more abstract representation of data, deep learning technology, which uses the multilayer neural networks, dominates the artificial learning nowadays.

Terapia intervencionista da embolia pulmonar aguda: onde estamos e para onde vamos? / Interventional therapy of acute pulmonary embolism: where are we and where are we heading towards?

A embolia pulmonar, uma doença com risco de vida, é prevalente em todo o mundo, afetando grande porcentagem da população e representando uma das principais causas de morte cardiovascular. Para reduzir sua mortalidade e morbidade e melhorar os desfechos, é fundamental uma estratificação precoce do risco. Há uma ampla variação na gravidade de uma embolia pulmonar, desde leve até com risco de vida. Quando um paciente tem uma embolia pulmonar de alto risco e está em choque ou parada cardíaca, é razoável realizar trombólise sistêmica ou embolectomia de emergência, mas a anticoagulação isolada tem ótimos resultados na embolia pulmonar de baixo risco. Há várias estratégias para aproveitar os benefícios da trombólise e minimizar seus riscos, mas a experiência clínica com essas novas estratégias de intervenção é limitada. A equipe de resposta à embolia pulmonar, composta de cardiologista intervencionista, radiologista intervencionista, cirurgião cardíaco, radiologista especializado em imagem cardíaca e intensivista, pode ajudar a determinar o tipo de intervenção em um determinado paciente. Este artigo traz um esboço das terapias intervencionistas endovasculares atuais e seu contexto.

This life-threatening condition, known as pulmonary embolism, is prevalent throughout the world, affecting a large percentage of population and representing one of the leading causes of cardiovascular death. To reduce mortality and morbidity and improve outcomes, early risk stratification is critical. There is a wide range in the severity of a pulmonary embolism, from mild to life-threatening. When a patient has a high-risk pulmonary embolism and is in shock or cardiac arrest, emergency systemic thrombolysis or embolectomy is reasonable, but anticoagulation alone has great results in low-risk pulmonary embolism. Multiple strategies exist to capture the benefits of thrombolysis while minimizing its risks, but clinical experience with such novel intervention strategies is limited. The pulmonary embolism response team comprises interventional cardiologist, interventional radiologist, cardiac surgeon, cardiac radiologist, and critical care specialist, can help determine the type of intervention in a given patient. This article provides an outline of current endovascular interventional therapies and their context.

Nanoceria and Its Biomedical Relevance

Nanoceria is a nanosized particle preparation of cerium oxide. It shows mixture of cerium in the 3+ and 4+ states on the nanoparticle surface, giving it interesting redox properties. Nanoceria shows effective biological antioxidant properties, which makes it a great candidate for biomedical applications. Many studies have shown promising results on therapeutic potential of nanoceria in diseases like cancer, diabetes, atherosclerosis, and neurodegenerative diseases. Meanwhile, other studies explored biodistribution and toxicity of nanoceria. This review article describes nanoceria, its relevant biomedical applications, and adverse effects, based on previously reported studies.

Coronary chronic total occlusion intervention: A pathophysiological perspective

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is the last frontier in coronary intervention. PCI of CTO carries multiple advantages, such as significant improvement in symptoms, improvement in abnormal wall motion and left ventricular function and, possibly, increased long-term survival. As of today the procedural success is markedly improved because of technical innovations and is limited to highly experienced operators. To enhance the overall success rate from a worldwide perspective, a thorough understanding of its pathophysiology is critical to further development of newer techniques and technologies. In this review, the author outlines in-depth the evidence that underpins our understanding of CTO pathophysiology and its insight into CTO intervention that incorporates various steps and techniques to cross the lesion.

Conformational change of L7/L12 stalk in the different functional states of 50S ribosomes.

Conformational change of 50S ribosomes takes place during protein synthesis. The primary change is most likely in the secondary or tertiary structure of rRNA in the L7/L12 stalk region. In order to throw further light on this conformational change, the change in fluorescence of tight couple 50S ribosomes on conversion to loose couple 50S ribosomes containing 5-(iodoacetamido ethyl)-aminonaphthalene-l-sulphonic acid-labelled L7/L12, following the treatment with elongation factor-G and 5'-guanylyl methylene diphosphate was measured. It was enhanced in agreement with the results reported earlier. Further, the quenching of fluorescence of 50S ribosomes containing 5-(iodoacetamido ethyl)- aminonaphthalene-1-sulphonic acid-labelled L7/L12 by acrylamide was studied. The quenching is more in case of loose couples. On conversion of loose couple 50S ribosomes to tight couple ones the quenching becomes less whereas the reverse happens on conversion of tight couple 70S ribosomes to loose couples. These results indicate the conformational change of L7/L12 stalk in the different functional states of 50S ribosomes.