Temporal Trends, Characteristics, and Outcomes of Infective Endocarditis After Transcatheter Aortic Valve Replacement

BACKGROUND: Procedural improvements combined with the contemporary clinical profile of patients undergoing transcatheter aortic valve replacement (TAVR) may have influenced the incidence and outcomes of infective endocarditis (IE) following TAVR. We aimed to determine the temporal trends, characteristics, and outcomes of IE post-TAVR. METHODS: Observational study including 552 patients presenting definite IE post-TAVR. Patients were divided in 2 groups according to the timing of TAVR (historical cohort [HC]: before 2014; contemporary cohort [CC]: after 2014). RESULTS: Overall incidence rates of IE were similar in both cohorts (CC vs HC: 5.45 vs 6.52 per 1000 person-years; P = .12), but the rate of early IE was lower in the CC (2.29‰ vs 4.89‰, P < .001). Enterococci were the most frequent microorganism. Most patients presented complicated IE (CC: 67.7%; HC: 69.6%; P = .66), but the rate of surgical treatment remained low (CC: 20.7%; HC: 17.3%; P = .32). The CC exhibited lower rates of in-hospital acute kidney injury (35.1% vs 44.6%; P = .036) and in-hospital (26.6% vs 36.4%; P = .016) and 1-year (37.8% vs 53.5%; P < .001) mortality. Higher logistic EuroScore, Staphylococcus aureus etiology, and complications (stroke, heart failure, and acute renal failure) were associated with in-hospital mortality in multivariable analyses (P < .05 for all). CONCLUSIONS: Although overall IE incidence has remained stable, the incidence of early IE has declined in recent years. The microorganism, high rate of complications, and very low rate of surgical treatment remained similar. In-hospital and 1-year mortality rates were high but progressively decreased over time.

Infective Endocarditis Following Transcatheter Aortic Valve Replacement: Comparison of Balloon- Versus Self-Expandable Valves.

BACKGROUND: No data exist about the characteristics of infective endocarditis (IE) post-transcatheter aortic valve replacement (TAVR) according to transcatheter valve type. We aimed to determine the incidence, clinical characteristics, and outcomes of patients with IE post-TAVR treated with balloon-expandable valve (BEV) versus self-expanding valve (SEV) systems. METHODS: Data from the multicenter Infectious Endocarditis After TAVR International Registry was used to compare IE patients with BEV versus SEV. RESULTS: A total of 245 patients with IE post-TAVR were included (SEV, 47%; BEV, 53%). The timing between TAVR and IE was similar between groups (SEV, 5.5 [1.2-15] months versus BEV, 5.3 [1.7-11.4] months; P=0.89). Enterococcal IE was more frequent in the SEV group (36.5% versus 15.4%; P<0.01), and vegetation location differed according to valve type (stent frame, SEV, 18.6%; BEV, 6.9%; P=0.01; valve leaflet, SEV, 23.9%; BEV, 38.5%; P=0.01). BEV recipients had a higher rate of stroke/systemic embolism (20.0% versus 8.7%, adjusted OR: 2.46, 95% CI: 1.04-5.82, P=0.04). Surgical explant of the transcatheter valve (SEV, 8.7%; BEV, 13.8%; P=0.21), and in-hospital death at the time of IE episode (SEV, 35.6%; BEV, 37.7%; P=0.74) were similar between groups. After a mean follow-up of 13±12 months, 59.1% and 54.6% of the SEV and BEV recipients, respectively, had died (P=0.66). CONCLUSIONS: The characteristics of IE post-TAVR, including microorganism type, vegetation location, and embolic complications but not early or late mortality, differed according to valve type. These results may help to guide the diagnosis and management of IE and inform future research studies in the field.

Infective endocarditis following transcatheter aortic valve replacement: comparison of balloon- versus self-expandable valves

BACKGROUND: No data exist about the characteristics of infective endocarditis (IE) post-transcatheter aortic valve replacement (TAVR) according to transcatheter valve type. We aimed to determine the incidence, clinical characteristics, and outcomes of patients with IE post-TAVR treated with balloon-expandable valve (BEV) versus self-expanding valve (SEV) systems. METHODS: Data from the multicenter Infectious Endocarditis After TAVR International Registry was used to compare IE patients with BEV versus SEV. RESULTS: A total of 245 patients with IE post-TAVR were included (SEV, 47%; BEV, 53%). The timing between TAVR and IE was similar between groups (SEV, 5.5 [1.2-15] months versus BEV, 5.3 [1.7-11.4] months; P=0.89). Enterococcal IE was more frequent in the SEV group (36.5% versus 15.4%; P<0.01), and vegetation location differed according to valve type (stent frame, SEV, 18.6%; BEV, 6.9%; P=0.01; valve leaflet, SEV, 23.9%; BEV, 38.5%; P=0.01). BEV recipients had a higher rate of stroke/systemic embolism (20.0% versus 8.7%, adjusted OR: 2.46, 95% CI: 1.04-5.82, P=0.04). Surgical explant of the transcatheter valve (SEV, 8.7%; BEV, 13.8%; P=0.21), and in-hospital death at the time of IE episode (SEV, 35.6%; BEV, 37.7%; P=0.74) were similar between groups. After a mean follow-up of 13±12 months, 59.1% and 54.6% of the SEV and BEV recipients, respectively, had died (P=0.66). CONCLUSIONS: The characteristics of IE post-TAVR, including microorganism type, vegetation location, and embolic complications but not early or late mortality, differed according to valve type. These results may help to guide the diagnosis and management of IE and inform future research studies in the field. (AU)

Pregnancy-associated spontaneous coronary artery dissection: insights from a case series of 13 patients.

AIMS: We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. METHODS AND RESULTS: Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient. CONCLUSION: In these 13 cases of P-SCAD, clinical presentation commonly included acute myocardial infarction and cardiogenic shock. Multivessel dissections and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of P-SCAD for prompt diagnosis and management in these high-risk patients.

Pregnancy-associated spontaneous coronary artery dissection: insights from a case series of 13 patients

AIMS: We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. METHODS AND RESULTS: Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient...

Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death.

IMPORTANCE: Limited data exist on clinical characteristics and outcomes of patients who had infective endocarditis after undergoing transcatheter aortic valve replacement (TAVR). OBJECTIVE: To determine the associated factors, clinical characteristics, and outcomes of patients who had infective endocarditis after TAVR. DESIGN, SETTING, AND PARTICIPANTS: The Infectious Endocarditis after TAVR International Registry included patients with definite infective endocarditis after TAVR from 47 centers from Europe, North America, and South America between June 2005 and October 2015. EXPOSURE: Transcatheter aortic valve replacement for incidence of infective endocarditis and infective endocarditis for in-hospital mortality. MAIN OUTCOMES AND MEASURES: Infective endocarditis and in-hospital mortality after infective endocarditis. RESULTS: A total of 250 cases of infective endocarditis occurred in 20 006 patients after TAVR (incidence, 1.1% per person-year; 95% CI, 1.1%-1.4%; median age, 80 years; 64% men). Median time from TAVR to infective endocarditis was 5.3 months (interquartile range [IQR], 1.5-13.4 months). The characteristics associated with higher risk of progressing to infective endocarditis after TAVR was younger age (78.9 years vs 81.8 years; hazard ratio [HR], 0.97 per year; 95% CI, 0.94-0.99), male sex (62.0% vs 49.7%; HR, 1.69; 95% CI, 1.13-2.52), diabetes mellitus (41.7% vs 30.0%; HR, 1.52; 95% CI, 1.02-2.29), and moderate to severe aortic regurgitation (22.4% vs 14.7%; HR, 2.05; 95% CI, 1.28-3.28). Health care-associated infective endocarditis was present in 52.8% (95% CI, 46.6%-59.0%) of patients. Enterococci species and Staphylococcus aureus were the most frequently isolated microorganisms (24.6%; 95% CI, 19.1%-30.1% and 23.3%; 95% CI, 17.9%-28.7%, respectively). The in-hospital mortality rate was 36% (95% CI, 30.0%-41.9%; 90 deaths; 160 survivors), and surgery was performed in 14.8% (95% CI, 10.4%-19.2%) of patients during the infective endocarditis episode. In-hospital mortality was associated with a higher logistic EuroSCORE (23.1% vs 18.6%; odds ratio [OR], 1.03 per 1% increase; 95% CI, 1.00-1.05), heart failure (59.3% vs 23.7%; OR, 3.36; 95% CI, 1.74-6.45), and acute kidney injury (67.4% vs 31.6%; OR, 2.70; 95% CI, 1.42-5.11). The 2-year mortality rate was 66.7% (95% CI, 59.0%-74.2%; 132 deaths; 115 survivors). CONCLUSIONS AND RELEVANCE: Among patients undergoing TAVR, younger age, male sex, history of diabetes mellitus, and moderate to severe residual aortic regurgitation were significantly associated with an increased risk of infective endocarditis. Patients who developed endocarditis had high rates of in-hospital mortality and 2-year mortality.

Association between transcatheter aortic valve replacement and subsequent infective endocarditis and in-hospital death

IMPORTANCE: Limited data exist on clinical characteristics and outcomes of patients who had infective endocarditis after undergoing transcatheter aortic valve replacement (TAVR). OBJECTIVE: To determine the associated factors, clinical characteristics, and outcomes of patients who had infective endocarditis after TAVR. DESIGN, SETTING, AND PARTICIPANTS: The Infectious Endocarditis after TAVR International Registry included patients with definite infective endocarditis after TAVR from 47 centers from Europe, North America, and South America between June 2005 and October 2015. EXPOSURE: Transcatheter aortic valve replacement for incidence of infective endocarditis and infective endocarditis for in-hospital mortality. MAIN OUTCOMES AND MEASURES: Infective endocarditis and in-hospital mortality after infective endocarditis. RESULTS: A total of 250 cases of infective endocarditis occurred in 20 006 patients after TAVR (incidence, 1.1% per person-year; 95% CI, 1.1%-1.4%; median age, 80 years; 64% men). Median time from TAVR to infective endocarditis was 5.3 months (interquartile range [IQR], 1.5-13.4 months). The characteristics associated with higher risk of progressing to infective endocarditis after TAVR was younger age (78.9 years vs 81.8 years; hazard ratio [HR], 0.97 per year; 95% CI, 0.94-0.99), male sex (62.0% vs 49.7%; HR, 1.69; 95% CI, 1.13-2.52), diabetes mellitus (41.7% vs 30.0%; HR, 1.52; 95% CI, 1.02-2.29), and moderate to severe aortic regurgitation (22.4% vs 14.7%; HR, 2.05; 95% CI, 1.28-3.28). Health care-associated infective endocarditis was present in 52.8% (95% CI, 46.6%-59.0%) of patients...

Desempenho dos stents farmacológicos de segunda geração com liberação de everolimus no tratamento de pacientes com lesões coronárias De Novo / Performance of second-generation everolimus-eluting stents in the treatment of patients with "De Novo" coronary lesions

Introdução: Os stents farmacológicos com eluição de everolimus (SEE) têm se mostrado seguros e efetivos em estudos clínicos randomizados. Este estudo avaliou a evolução clínica tanto inicial como tardia de pacientes tratados na prática diária com SEE. Métodos: Estudo retrospectivo com portadores de doença coronária isquêmica tratados exclusivamente com SEE. Foram incluídos pacientes com lesõesde novo, em vasos nativos, sem qualquer restrição ao quadro clínico de apresentação. Acompanhamento tardio foi realizado para avaliar a ocorrência de óbito, infarto agudo do miocárdio (IAM) ou necessidade de revascularização do vaso-alvo (RVA). Resultados: A média de idade foi de 62,1 + 11,9 anos, dois terços eram do sexo masculino, com elevado porcentual de pacientes diabéticos (49,2%), e 51,6% eram portadores de angina estável. Doença multiarterial estava presente em 54,8%, com disfunção moderada a grave do ventrículo esquerdo em 11,3%. Predominaram as lesões complexas B2/C (79%), com implante monitorizado pelo ultrassom intracoronário em 57,3% dos casos. Ao menos uma indicação off-label ocorreu em quase 60% dos pacientes. Nos primeiros 30 dias observou-se IAM em 2,4%, RVA em 1,6% e trombose do stent em 1,6%. Com seguimento clínico de 92% dos pacientes, por período médio de 16 meses, observou-se reintervenção em apenas 0,9% e nenhum IAM adicional. Nenhum óbito foi constatado nessa população de pacientes. Conclusões: Os resultados deste estudo sugerem que o implante de SEE em uma população não-selecionada é seguro, com reduzida ocorrência de eventos adversos a longo prazo.

Background: Everolimus-eluting stents (EES) have proven to be safe and effective in randomized clinical trials. This study evaluated the early and late clinical follow-up of patients treated with EES in the daily practice. Methods: Retrospective study in patients with ischemic coronary disease treated with ESS alone. Patients with “de novo” lesions, in native vessels, were included. Patients were evaluated in the long-term follow-up for the occurrence of death, acute myocardial infarction (AMI) or the need of target-vessel revascularization (TVR). Results: Mean age was 62.1 + 11.9 years, 75% were male, there was a high percentage ofdiabetics (49.2%) and 51.6% had stable angina. Multivessel disease was observed in 54.8% and moderate tosevere left ventricular dysfunction in 11.3%. There was a prevalence of complex B2/C lesions (79%), and the procedure was monitored by intravascular ultrasound in 57.3% of the cases. At least one off-label indication was observed in nearly 60% of the patients. At 1-month follow-up AMI was observed in 2.4%, TVR in 1.6% and stent thrombosis in 1.6% of the patients. Complete long-term data were obtained in 92% of the overall cohort, with a mean follow-up of 16 months. TVR was observed in only 0.9% of the patients and there was no additional AMIs. There were no deaths in this population. Conclusions: The results of this study suggest that EES implantation in a non-selected population is safe, with a low rate of long-term adverse events.

Análise comparativa de segurança e eficácia entre as vias de acesso radial e femoral na realização de intervenção coronária percutânea no infarto agudo do miocárdio / Safety and efficacy of radial versus femoral approach in percutaneous coronary intervention in acute myocardial infarction

INTRODUÇÃO: A intervenção coronária percutânea é a estratégia mais adequada de reperfusão no infarto agudo do miocárdio. A intervenção coronária percutânea pela via radial nas síndromes estáveis é uma alternativa efetiva, comparativamente ao acesso pela via femoral, com redução do risco de complicações hemorrágicas e vasculares. Este estudo teve como objetivo avaliar a segurança e a efetividade da intervenção coronária percutânea pela via radial no infarto agudo do miocárdio em uma série consecutiva de pacientes. MÉTODO: Entre janeiro de 1997 e julho de 2009, 387 pacientes foram tratados por intervenção coronária percutânea nas primeiras 12 horas de infarto agudo do miocárdio, sendo excluídos os pacientes em choque cardiogênico e aqueles submetidos a angioplastia de ponte de safena e angioplastia com balão. Foram realizadas 132 angioplastias transluminais coronárias por via radial (34,8%) e 247 por via femoral (65,2%). RESULTADOS: Obteve-se elevado sucesso angiográfico (95,6% vs. 96,8%; P = 0,57), com o mesmo porcentual de perfusão miocárdica pós-procedimento, independentemente da via de acesso utilizada. Aos 30 dias de evolução, observou-se tendência a menor incidência de eventos no grupo em que foi utilizada a via radial (1,5% vs. 6,9%; P = 0,07), possivelmente pela menor ocorrência de trombose do stent nesse grupo (0,8% vs. 4,9%; P = 0,04) e pela menor necessidade de nova revascularização percutânea do vaso-alvo (0,8% vs. 4,9%; P = 0,04). Não foram observadas diferenças na incidência de hemorragias maiores entre os dois grupos (2,3% vs. 2%; P > 0,99). CONCLUSÕES: O presente estudo sugere que o acesso pela via radial na angioplastia primária em pacientes elegíveis é seguro e eficaz quando o procedimento é realizado por intervencionistas "radialistas", sendo uma alternativa atrativa ao acesso femoral, especialmente naqueles pacientes com alto risco de complicações vasculares associadas à via de acesso, como os obesos e os que recebem inibidores da glicoproteína IIb/IIIa e trombolíticos.

BACKGROUND: Percutaneous coronary intervention (PCI) is the most appropriate reperfusion strategy in acute myocardial infarction. PCI by the radial approach in stable coronary syndromes is an effective alternative when compared to the femoral approach, with reduced risk of bleeding and vascular complications. This paper is aimed at evaluating the safety and efficacy of PCI in acute myocardial infarction by the radial approach in a series of consecutive patients. METHOD: From January 97 to July 2009, 387 patients were treated by PCI within 12 hours of acute myocardial infarction. Patients with cardiogenic shock and those undergoing balloon angioplasty or saphenous vein graft PCI were excluded. One hundred and thirty-two PCI by radial approach (34.8%) and 247 by femoral approach (65.2%) were carried out. RESULTS: High angiographic success (95.6% vs. 96.8%; P = 0.57) was observed with the same rate of post-procedure myocardial perfusion, regardless of the approach used. After 30 days, there was a trend towards lower incidence of events in the radial approach group (1.5% vs. 6.9%; P = 0.07), possibly due to the lower occurrence of stent thrombosis in this group (0.8% vs. 4.9%; P= 0.04) and less need of target vessel revascularization (0.8% vs. 4.9%; P = 0.04). There was no difference in the incidence of major bleeding between the two groups (2.3% vs. 2%; P > 0.99). CONCLUSIONS: The present study suggests that the radial approach in primary angioplasty is safe and effective when performed by interventional "radialists" in eligible patients, and is an attractive alternative to the femoral approach, especially in patients at high risk of vascular complications such as obese patients and those receiving glycoprotein IIb/IIIa inhibitors or thrombolytics.

Letalidade hospitalar e tardia após angioplastias coronarianas com stents convencionais e farmacológicos / In-hospital and late mortality after coronary angioplasty with bare metal and drug eluting stents

Avanços nas intervenções coronarianas com cateter, especialmente com o uso dos stents convencionais (SC) e farmacológicos (SF), têm melhorado a eficácia e a segurança da revascularização percutânea. Analisar a letalidade hospitalar e tardia das angioplastias coronarianas realizadas no período de 2002 a 2005, com implante de SF e SC. Foram selecionados pacientes no período de junho 2002 a dezembro 2005 tratados por intervenção coronariana percutânea com implante exclusivo de SC ou SF em hospitais privados do Rio de Janeiro e Niterói...

Utilização off-label dos stents farmacológicos nas intervenções coronárias percutâneas: registro da Clínica São Vcente / Off-label utilization of drug-eluting stents in percutaneous coronary intervention: Clinica São Vicente registry

Fundamentos: Estudos clínicos randomizados indicam que os stents farmacológicos reduzem a taxa de reestenose e a necessidade de procedimentos de revascularização. Objetivo: Avaliar o desempenho dos stents farmacológicos no mundo-real, comparando a evolução dos pacientes elegíveis nos estudos randomizados (on-label) com aqueles inelegíveis para intervenção coronária percutânea com stents farmacológicos (off-label). Método: Entre junho de 2002 e dezembro de 2007, 653 pacientes foram tratados por intervenção coronária percutânea somente con stents farmacológicos: 309 pacientes com stents farmacológicos em indicações on-label (309 stents) e 344 pacientes com presença de ao menos uma indicação off-label (654 stents). Foram consideradas indicações off-label: fração de ejeção < 25 por cento, múltiplos stents, oclusão crônica, tronco não protegido, bifurcação, ponte de safena, infarto agudo, lesão ostial e lesão reestenótica. Avaliamos a evolução hospitalar e no período médio de 23,2 meses após o procedimento. Resultados: Sucesso angiográfico elevado, com maior ocorrência de no-reflow (0 por cento vs. 1,5 por cento; p = 0,04) e mionecrose (1,9 por cento vs. 5,2 por cento; p = 0,022), foi observado nos pacientes off label, porém sem diferença na mortalidade (0,3 por cento vs. 0,9 por cento; p = 0,3). No seguimento tardio de 80 por cento dos pacientes...

Background: Randomized clinical trials indicate that drugeluting stents (DES) reduce the rates of restenosis and need for subsequent revascularization procedures. Objective: This study examined the performance of DES in a 'real world' setting comparing the outcomes of trial-eligible (on-label) versus ineligible (off-label) patients undergoing percutaneous coronary interventions. Methods: From June 2002 to December 2007, 653 patients underwent percutaneous coronary intervention exclusively using DES: 309 patients (309 stents) with on-label indications, and 344 patients (654 stents) with at least one off-label indication. Off-label indications were considered ejection fraction < 25%, multiple DES, chronic total occlusions, unprotected left main coronary artery, bifurcations, saphenous vein grafts, acute myocardial infarction, ostial or restenotic lesions. We evaluated in-hospital as well as late follow-up events. Results: A high angiographic success, but with higher in-hospital myonecrosis (1.9% vs 5.2%; p = 0.02) and noreflow phenomenon (0% vs 1.5%; p = 0.04), was observed with off-label use; the incidence of death (0.3% vs 0.9%; p = 0.3) was not statistically different between groups. Data obtained from 80% of the patients over an average 23.2-month follow-up period showed a low incidence of major adverse cardiac events (8% vs. 8.1%; p = 0.5) and target vessel revascularization procedures (6.8% vs. 5.1%; p = 0.2). Conclusion: Off-label implantation of DES is safe, with a low mortality rate. DES use in this complex cohort of patients does not confer a higher risk of late adverse cardiac events or repeat revascularizations when compared to on-label indications.

Implante contemporâneo de stents convencionais: comparação dos stents de hastes finas de aço inoxidável versus cromo-cobalto / Contemporary bare metal stents implantation: comparison of stainless steel versus cobalt chromium coronary stents

Introdução: A maior espessura das hastes dos stents coronários está associada a maior risco de reestenose pós-implante de stents convencionais. Novos stents convencionais com hastes finas têm sido desenvolvidos, porém poucos estudos comparando esses novos dispositivos estão disponíveis. Método: No período de fevereiro de 2004 a janeiro de 2007, 475 pacientes consecutivos foram tratados exclusivamente com stents convencionais de hastes finas: 111 com stents de aço inoxidável (Liberté® - grupo I) e 364 com implante de stents de liga de cromo-cobalto (Driver® - grupo II). Foram abordadas lesões de novo em vasos nativos, sendo excluídos enxertos de safena, reestenoses de stent e pacientes em choque cardiogênico. Os pacientes foram avaliados quanto à evolução tanto hospitalar como tardia. Resultados: Sucesso angiográfico foi obtido na quase totalidade dos casos, com reduzida ocorrência de complicações cardíacas na fase hospitalar. No período médio de 18 meses, não foram observadas diferenças entre os stents, com baixa incidência de eventos cardíacos maiores (10,1% vs. 7,3%; p = 0,2) e da necessidade de revascularização do vaso-alvo (8,6% vs. 6,9%; p = 0,3). Conclusão: O implante da nova geração de stents coronários convencionais com hastes de fina espessura, no tratamento de lesões de novo em população selecionada, reduz a necessidade de reintervenção para níveis abaixo de 10%, com resultados similares entre os dispositivos avaliados.

Introduction: Higher strut thickness of coronary bare metal stents is associated with restenosis risk after bare metal stent implantation. New bare metal stents with thin struts have been developed, but there have been few studies comparing these new devices. Methods: from February 2004 until January 2007, 475 consecutive patients underwent percutaneous coronary intervention treating “de novo” coronary lesions exclusively using BMS. One hundred and eleven patients with stainless steel stent (Liberté® - group I) and 364 with cobalt chromium stent (Driver® - group II). Bypass venous graft, cardiogenic shock and restenosis were excluded. Patient progress was evaluated during their hospital stay and an average 18-month outpatient follow-up. Results: Angiographic success in almost all cases, with reduced in-hospital cardiac complications. Over an average 18-month period we found a low incidence of major adverse cardiac events (10.1 vs 7.3%; p=0.2) and a reduction in target vessel revascularization procedures (8.6 vs 6.9%; p=0.3). Conclusion: Implantation of new generation BMS with thinner-struts to treat “de novo” coronary lesions, in a select population, reduces target vessel revascularization to below 10%, with both devices achieving similar results.

Fratura de stent como causa de reestenose em stent farmacológico / Stent fracture and restenosis of drug-eluting-stents

Os stents coronários são usados em mais de 90 por cento das intervenções coronárias percutâneas. Emtretanto, sua eficácia está limitada pela ocorrência de reestenose, variando de 15 por cento a 50 por cento dos casos, dependendo da morfologia da lesão e da presença de co-morbidade (como, por exemplo, diabetes melito e insuficiência renal). Nos últimos anos os stents farmacológicos provaram ser eficazes em suprimir a hiperplasia neo-intimal, reduzindo a taxa de reestenose para um dígito. Neste artigo, os autores descrevem um caso de reestenose em stent com eluição de sirolimus relacionada à fratura de stent.

The latest great revolution in the management of restenosis has been the introduction of the drug-eluting-stents (DES). They have been proven very effective in suppressing neointimal proliferation and reduces restenosis rates to single digit numbers. A case of DES strut fracture-induced restenosis is described.

Formação expansiva mediastinal após angioplastia percutânea / Mediastinal mass after percutaneous transluminal coronary angioplasty

A descrição de relatos de caso tem o objetivo de mostraro os números diagnósticos possíveis numa determinada situação clínica, bem como o raciocínio e os métodos de investigação que foram utilizados pela equipe médica envolvida. Será discutido o diagnóstico de formação expansiva mediastinal que surgiu após angioplastia percutânea.

Angioplastia renal transluminal percutânea no tratamento da hipertensäo renovascular / Percutaneous Transluminal Renal Angioplasty for Treatment of Renovascular Hypertension

Objetivo - Avaliar o efeito da angioplastia renal transluminal percutânea (ARTP) no tratamento da hipertensäo renovascular. Métodos - Foram avaliados 23 pacientes com estenose da artéria renal e hipertensäo arterial submetidos à tentativa de ARTP. Onze indivíduos eram do sexo masculino e 12 do feminino com idades que variaram de 10 a 78 anos (45,8 ñ 17,41). Vinte Lesöes eram ateroscleróticas, 7 por displasia fibromuscular e 1 por arterite de Takayasu. Em 3 casos a dilataçäo foi bilateral e em 2 foi repetida por reestenose. Dois pacientes apresentavam insuficiencia renal aguda por estenose crítica das artérias renais. Resultados - Obteve-se sucesso técnico em 21 dos 25 procedimentos. Após 20 dilataçöes satisfatórias seguiu-se o sucesso clínico em 17(100// das lesöes por displasia fibromuscular e 77// das ateroscleróticas). A reduçäo da pressäo arterial diastólica após a ARTP foi estatisticamente significante (p<0,001). Nos dois casos de insuficiência renal aguda houve normalizaçäo da funçäo renal com a angioplastia. Ocorreram 2 complicaçöes e nenhum óbito foi relacionado ao procedimento. Conclusäo - O método foi eficaz e seguro no tratamento da hipertensäo renovascular no acompanhamento a curto prazo. Foi possível reverter a insuficiência renal aguda com a ARTP em 2 pacientes

Purpose - To analyze the effect of percutaneous transluminal renal angioplasty (PTRA) in renovascular hypertension. Methods - Twenty-three patients with renal artery stenosis and arterial hypertension underwent PTRA. There were 11 male an 12 female, 19 to 78 years old (45.8±17.41). In 20 lesions the diagnosis was atherosclerosis, in 7 fibromuscular dysplasia and in 1 Takayasu artheritis. Three patients underwent bilateral dilatation and 2 patients repeated the procedure due to reestenosis. Two patients presented with acute renal failure and severe bilateral renal artery stenosis. Results - There were 21 technical success in 25 procedures. After 20 satisfatory dilatations, clinical success followed in 17 (100% of cases of fibromascular dysplasia cases and 77% of atherosclerosis. The fall in diastolic arterial pressure after PTRA was statistical significant (p<0.001). In two cases acute renal failure the renal function became normal after angioplasty. There were 2 complications and no death attributed to PTRA. Conclusion - The method was effective and safe in the management of renovascular hypertension during the short-term follow-up. It was possible in two cases of acute renal failure to normalize renal function

Angioplastia de aorta distal e artérias ilíaca, femoral, poplítea, renal e subclávia: resultados imediatos e tardios / Distal aorta, femoral, poplietal, renal and subclavian percutaneous transluminal angioplasty. early and late results

Estudar os resultados da angioplastia periférica a longo prazo. Entre agosto de 1981 e agosto de 1989 foram aplicadas 33 angioplastias periféricas em 27 pacientes. Houve sucesso em 29 procedimentos, dilataçäo insuficiente em 1 e falha de passagem nos demais 3,2 dos quais submetidos a novo procedimento com modificaçäo técnica ou outra via de acesso, obtendo'se em ambos sucesso. Houve portanto sucesso em 88% dos procedimentos e atingiu'se o objetivo em 25 (93%) dos pacientes. Foram dilatadas 34 obstruçöes, sendo 12 em artéria renal, 12 em ilíaca primitiva; 4 em ilíaca externa, 3 em femoral superficial, 1 em poplítea, 1 em subclávia e, finalmente, 1 em poplítea, 1 em aorta distal. Na evoluçäo, houve uma reestenose de artéria renal, que foi redilatada, 1 oclusäo de ilíaca primitiva representando 9% das dilataçöes de ilíaca primitiva e 6% do total de obstruçöes de ilíacas dilatadas e oclusäo de poplítea. No geral, das 34 obstruçöes dilatadas, tivemos uma patência até de 2 meses de 91%. A angioplastia periférica mostrou-se método efetivo, com alívio sintomático epersistência dos bons resultados a longo prazo

Angioplastia transluminal percutânea da arteria subclávia esquerda em um paciente com síndrome do roubo coronária-subclávia / Percutaneous transluminal angioplasty of left subclavian artery in patient with coronary-subclavian steal syndrome

Os autores apresentam o caso de um paciente submetido a cirurgia de revascularizaçäo miocárdica há 10 anos com anastomose da artéria mamária interna esquerda-artéria coronária descendente anterior e que há cerca de 2 meses voltou a apresentar dor precordial típica progressiva. Foi realizado estudo hemodinâmico que revelou anastomose mamária-coronária patente e lesäo obstrutiva severa da artéria subclávica esquerda, caracterizando-se assim a síndrome do roubo coronária-subclávia. O paciente foi entäo submetido a angioplastia transluminal percutânea da artéria subclávia esquerda com sucesso ocorrendo remissäo dos sintomas. Obteve-se o acompanhamento clínico do paciente, assintomático do ponto de vista cardiológico por 1 ano e 8 meses, quando entäo veio a falecer em decorrência de acidente vascular encefálico. Os autores recomendam atençäo especial as lesöes obstrutivas das artérias subclávias, com a realizaçäo de estudo angiográfico dos troncos supra-aórticos, especialmente naqueles pacientes com doença aterosclerótica difusa e/ou sinais de doença isquêmica cérebro-vascular e dos membros superiores, seja em pacientes que iräo submeter-se a cinecoronariografia e que potencialmente poderäo ter utilizadas as artérias mamárias para revascularizaçäo miocárdica, seja em pacientes submetidos a cirurgia de revascularizaçäo com o uso da artéria mamária e que voltam a apresentar angor e que no reestudo angiográfico mostram a anastomose patente

Trombólise no infarto agudo do miocárdio: aspectos clínicos e sequência terapêutica / Thrombolysis in acute myocardial infarction: clinical and therapeutic aspects

Foram estudados 32 pacientes com infarto agudo do miocárdio, submetidos a infusäo venosa de estreptoquinase (SK). Os pacientes foram divididos em dois grupos, de acordo com o intervalo entre o início dos sintomas e a administraçäo da SK (Delta t). O grupo I com Delta T menor ou igual a 4 horas apresentou o índice de reperfusäo de 85,7% e o grupo II com Delta t superior a 4 horas teve 81,8% de vasos recanalizados. Procedimentos seqüências ao uso do trombolítico configuram-se como: a) angioplastia percutânea transluminal coronária (APTC) em dez pacientes, b) cirurgia de revascularizaçäo miocárdica (RM) em outros dez pacientes. A mortalidade hospitalar foi de 3,1%. Näo houve complicaçöes graves ao uso da SK. O uso da SK - IV parece ser seguro e eficaz como parte do tratamento em pacientes com infarto agudo do miocárdio com menos de 6 horas de evoluçäo