Atrial flutter and embolic risk: The relationship between atrial flutter cycle length and left atrial appendage function.

BACKGROUND: The potential for thromboembolism in atrial flutter (AFL) is different from atrial fibrillation. AFL cycle length (AFL-CL) may be related to reduced left atrial appendage (LAA) function. Very rapid AFL-CL can lead to mechanical and electrophysiological disorders that contribute to lower LAA emptying velocity (LAEV). The aim of this study is to relate atrial flutter cycle length with LAEV and its role in thrombogenesis. METHODS: Cross-sectional study of patients with atrial flutter AFL who underwent transoesophageal echocardiography (TEE) before catheter ablation or electric cardioversion. AFL-CL in milliseconds was measured with a 12-lead EKG or in intracardiac records. RESULTS: We included 123 patients. There was correlation between AFL-CL and LAEV (r = 0.34; p = 0.003) in typical AFL. Cycle length, LA size and atypical flutter were predictors of low LAEV on multivariate analysis. An index multiplying atrial rate (bpm) during the arrhythmia versus left atrial size(mm) >11,728 was associated with spontaneous echogenic contrast and/or left atrial thrombus on TEE (C-statistic = 0.71; CI95%0.60-0.81). CONCLUSIONS: There was a significant relationship between the AFL-CL and LAEV. The LAEV was affected by the LA size, the type of atrial flutter and the AFL-CL. A new index, relating the atrial rate with the left atrial size, was able to identify a higher occurrence of spontaneous echogenic contrast and/or left atrial thrombus.

Aspiration thrombectomy prior to percutaneous coronary intervention in ST-elevation myocardial infarction: a systematic review and meta-analysis.

BACKGROUND: Trials of aspiration thrombectomy (AT) prior to primary percutaneous intervention (PCI) in patients with ST-segment elevation MI (STEMI) have shown apparently inconsistent results and therefore generated uncertainty and controversy. To summarize the effects of AT prior to PCI versus conventional PCI in STEMI patients. METHODS: Searches of MEDLINE, EMBASE and CENTRAL to June 2015 and review of reference lists of previous reviews. We included randomized controlled trials (RCTs) comparing AT prior to PCI with conventional PCI alone. Pairs of reviewers independently screened eligible articles; extracted data; and assessed risk of bias. We used the GRADE approach to rate overall certainty of the evidence. RESULTS: Among 73 potential articles identified, 20 trials including 21,660 patients were eligible; data were complete for 20,866 patients. Moderate-certainty evidence suggested a non statistically significant decrease in overall mortality (risk ratio (RR) 0.89, 95 % confidence interval, 0.78 to 1.01, risk difference (RD) 4/1,000 over 6 months), no impact on recurrent MI (RR 0.94, 95 % CI, 0.79 to 1.12) or major bleeding (RR 1.02, 95 % CI, 0.78 to 1.35), and an increase in stroke (RR 1.56, 95 % CI, 1.09 to 2.24, RD 3/1,000 over 6 months). CONCLUSIONS: Moderate certainty evidence suggests aspiration thrombectomy is associated with a possible small decrease in mortality (4 less deaths/1000 over 6 months) and a small increase in stroke (3 more strokes/1000 over 6 months). Because absolute effects are very small and closely balanced, thrombectomy prior to primary PCI should not be used as a routine strategy.

Desfechos clínicos tardios de pacientes diabéticos tratados com stents farmacológicos eluidores de sirolimus ou everolimus: uma análise do registro DESIRE / Late clinical outcomes of diabetic patients treated with sirolimus or everolimus drug-eluting stents: an analysis of the DESIRE registry

Stents farmacológicos (SF) de segunda geração demonstraram melhor desempenho clínico que os de primeira geração, sobretudo pela redução nas taxas de trombose, mas ainda não está claro se esse benefício se estende a diabéticos da prática diária. Objetivamos comparar o desempenho de pacientes diabéticos não selecionados tratados com SF eluidores de sirolimus (SES; primeira geração) vs. SF eluidoresde everolimus (SEE; segunda geração).Métodos: Entre 2007 e 2014, 798 diabéticos foram tratados com SES (n = 414) ou SEE (n = 384) e incluídosnesta análise. Seguimento clínico tardio foi obtido em 99,4% da população e os grupos foram comparados quanto à ocorrência de eventos cardíacos adversos maiores (ECAM) e trombose de stent. Resultados: A idade da população foi semelhante, com predomínio do sexo masculino. Em ambas as coortes, a apresentação clínica mais frequente foi a doença coronária estável. Número de vasos tratados (1,50 ± 0,62 vs. 1,52 ± 0,72; p = 0,88) e extensão total de stents (36,1 ± 20,4 mm vs. 37,7 ± 22,2 mm; p = 0,32) foram semelhantes. Os pacientes tratados com SEE apresentaram menores taxas de ECAM (15% vs. 6,8%; p < 0,001), sobretudo à custa de menor mortalidade cardíaca (5,3% vs. 1,3%; p < 0,001). Observou-se também menor ocorrência de trombose de stent definitiva/provável com SF de segunda geração (3,4% vs. 0,5%; p = 0,004).Conclusões: Nesta experiência unicêntrica, o uso de SEE em diabéticos mostrou-se com menor mortalidadecardíaca e trombose da endoprótese. Esse benefício se fez mais evidente no seguimento mais tardio...

Despite the better clinical performance of second-generation drug-eluting stents (DES)when compared to first-generation DES in controlled trials, mainly due to reduction in thrombosis rate, it remains unclear whether this benefit extends to diabetic patients treated in the daily practice. We sought to compare the clinical outcomes of unselected diabetic patients treated with either sirolimus eluting stents - SES (first-generation DES) or everolimus-eluting stents - EES (second-generation DES). Methods: Between January 2007 and October 2014 a total of 798 diabetic patients were treated with SES(n = 414) and EES (n = 384). Long-term clinical follow-up was achieved in 99,4% of the population andthe groups were compared regarding the occurrence of major adverse cardiac events (MACE) and stent thrombosis. Results: In both cohorts age was similar, and most patients were male. Stable coronary disease was the most frequent clinical presentation. The number of treated vessels (1.50 ± 0.62 vs. 1.52 ± 0.72; p = 0.88)and the total stent length (36.1 ± 20.4 vs. 37.7 ± 22.2 mm; p = 0.32) were similar between groups. Patients treated with EES showed lower rates of MACE (15% vs. 6.8%, p < 0.001), mainly due to a lower cardiac death(5.3% vs. 1.3%, p < 0.001). There was also less definitive/ probable thrombosis with the second generation DES (3.4% vs. 0.5%, p = 0.004)...

Evolução tardia de pacientes com lesões coronárias complexas tratados com o novo Stent Metálico MGuardTM / Late clinical follow-up of patients with complex coronary lesions treated with the new MGuardTM Bare-Metal Stent

INTRODUÇÃO: A embolização de fragmentos de ateroma/trombo durante a intervenção coronária percutânea (ICP) ocasiona distúrbios de perfusão da microcirculação. O novo stent MGuardTM, que é revestido com uma rede de polietileno, demonstrou eficácia na prevenção de complicações embólicas durante a ICP primária. No entanto, a evolução clínica tardia de pacientes tratados com o stent MGuardTM permanece desconhecida. MÉTODOS: Uma série de 65 pacientes portadores de lesões coronárias de novo tratados com o stent MGuardTM foi analisada. Os dados clínicos basais, do procedimento e do seguimento clínico tardio (média de tempo, 2,6 ± 1,4 anos) foram coletados retrospectivamente por meio da revisão de prontuários médicos e/ou contato telefônico direto. RESULTADOS: A média de idade foi de 66,1 ± 13,7 anos, 32,3% eram diabéticos, 49,2% tinham infarto agudo do miocárdio (IAM) prévio, e 44,6% apresentaram-se com síndrome coronária aguda. Dois terços das lesões estavam localizados em pontes de safena, quase metade tinha presença de trombo e a maioria foi classificada como tipo B2/C. O stent MGuardTM foi implantado com sucesso em todos os casos. Ao final do procedimento, fluxo TIMI 3 foi alcançado em 93,4% e o sucesso angiográfico foi de 91,8%. No seguimento tardio, as taxas de eventos adversos incluíram óbito cardiovascular em 6,2%, IAM não-fatal em 9,2%, revascularização da lesão-alvo em 9,2% e trombose de stent definitiva/provável em 1,5%. CONCLUSÕES: O seguimento tardio de pacientes com lesões coronárias complexas tratados com o stent MGuardTM demonstrou baixas taxas de revascularização da lesão-alvo e de trombose do stent.

BACKGROUND: The embolization of atheroma/thrombus fragments during percutaneous coronary intervention (PCI) causes microcirculatory perfusion disturbances. The new MGuardTM, a mesh-based bare-metal stent, demonstrated efficacy in the prevention of embolic complications during primary PCI. However, the late clinical outcome of patients treated with the MGuardTM stent remains unknown. METHODS: A series of 65 patients with de novo coronary lesions treated with MGuardTM stent was analyzed. Baseline clinical data, procedure and late clinical follow-up (mean duration, 2.6 ± 1.4 years) data were collected retrospectively by a review of medical records and/or direct telephone contact. RESULTS: Mean age was 66.1 ± 13.7 years, 32.3% of patients were diabetic, 49.2% had a previous acute myocardial infarction (AMI), and 44.6% presented with acute coronary syndrome. Two thirds of the lesions were located in a saphenous vein graft, almost half of the lesions had thrombus and most were classified as type B2/C. The MGuardTM stent was successfully implanted in all cases. At the end of the procedure, TIMI 3 flow was achieved in 93.4% and angiographic success was 91.8%. In the late clinical follow-up, adverse event rates included cardiac death in 6.2%, non-fatal AMI in 9.2%, target lesion revascularization in 9.2% and definite/probable stent thrombosis in 1.5%. CONCLUSIONS: The late follow-up of patients with complex coronary lesions treated with the MGuardTM stent demonstrated low rates of target lesion revascularization and stent thrombosis.

'Mother-in-child' thrombectomy technique: a novel and effective approach to decrease intracoronary thrombus burden in acute myocardial infarction.

BACKGROUND: The presence of large thrombus burden in patients presenting with acute myocardial infarction (AMI) is common and associated with poor prognosis. This study aimed to describe the feasibility and safety of the novel 'mother-in-child' thrombectomy (MCT) technique in patients presenting with AMI and large thrombus burden undergoing percutaneous coronary intervention (PCI). METHODS: We studied 13 patients presenting with AMI who underwent PCI with persistent large intracoronary thrombus after standard thrombectomy. The procedure was performed using a 5F 'Heartrail II-ST01' catheter (Terumo Medical) into a 6F guiding system. Angiographic assessment of thrombus burden and coronary flow was obtained at baseline, immediately after thrombectomy and at the end of the procedure. RESULTS: The mean age was 55.9±13.0 years and involved mostly males (76.9%). All patients underwent PCI via radial approach. Following MCT Thrombolysis In Myocardial Infarction (TIMI) flow improved by 2 or more degrees in 11 patients (84.5%), while visible angiographic thrombus was reduced in 11 patients (84.5%). In the final angiogram, normal TIMI flow was restored in 11 patients (84.5%), with normal myocardial 'blush' in 7 patients (53.8%) and total clearance of a visible thrombus in 7 patients (53.8%). Overall, 6 patients received thrombectomy as 'stand-alone' procedure. All patients were discharged alive after a mean of 5.6±2 days. CONCLUSION: This initial report suggests that significant reduction in thrombus burden and improvement of the coronary flow can be safely achieved in patients presenting with AMI and large thrombus burden by using the novel MCT technique.

Right atrial thrombus mimicking myxoma with pulmonary embolism in a patient with systemic lupus erythematosus and secondary antiphospholipid syndrome.

Antiphospholipid syndrome is a well-defined entity that is characterized by spontaneous abortion, thrombocytopenia, and recurrent arterial and venous thromboses. A partially calcified right atrial thrombus mimicking myxoma with recurrent pulmonary embolism has not been previously reported in a patient who also had systemic lupus erythematosus and secondary antiphospholipid syndrome. Herein, we describe the case of a 37-year-old woman with systemic lupus erythematosus and secondary antiphospholipid syndrome who was admitted to the hospital with progressive exertional dyspnea. Ventilation-perfusion scanning showed multiple parenchymal defects in the lungs that portended pulmonary embolism. In addition, the scanning revealed normal regional ventilation. Transthoracic and transesophageal echocardiography showed a right atrial mass that was highly suggestive of myxoma, and the patient subsequently underwent surgery. A histologic examination showed an organized, partially calcified thrombus. Intracardiac thrombus has been rarely reported as a complication of antiphospholipid syndrome. In our patient, the preoperative investigations could not differentiate the partially calcified right atrial thrombus from a myxoma, and the diagnosis was made postoperatively.

[Troponins and the indication for treatment with IIb/IIa inhibitors in acute coronary syndromes without ST-segment elevation. Is it time for an "INR" value of troponins?]. / Las troponinas y la indicación de los inhibidores IIb/IIIa en los síndromes coronarios agudos sin elevación del segmento ST. Es tiempo de un valor "INR" de troponinas?

At the present time non-ST elevation acute coronary syndromes are the most important cause of hospital admissions. Troponin determination in clinical practice is a key element of diagnosis, risk evaluation and prognosis, and now, defines the population that will benefit from IIb/IIIa inhibitors treatment. Probably a "universal standard value of Troponins" is needed to uniform our therapeutic criteria. The "minor elevations" for troponin-I are considered < 0.4 ng/dL and 0.5 ng/dL for troponin-T. The treatment of non ST elevation acute myocardial infarction with IIb/IIIa inhibitors may reduce the total amount of troponins and myocardial damage.

Pathophysiology of atherosclerotic plaque development and rupture: an overview.

Atherosclerosis is predominantly a clinically silent process, and a substantial percentage of patients are first aware of its consequences through the acute and catastrophic event of thrombosis. Extensive basic and clinical research in the 1990s revealed that plaque disruption initiates the majority of thromboses. Furthermore, recent studies indicate that inflammation plays a major role in the pathophysiology, from initiation of the atheroma to the actual thrombosis itself. Attention has now focused on morphological, mechanical, and biochemical characteristics that increase plaque vulnerability, as determination of these features may allow identification of plaques that are most likely to cause symptoms and acute events in the future. This article reviews basic pathophysiologic aspects of atherosclerotic plaque development and rupture to provide the necessary background for understanding the crucial role of inflammation in acute coronary syndromes.

Antitrombina III en diabetes mellitus no insulinodependiente de pacientes con infarto del miocardio / Antithrombin III in non insulin dependent diabetes mellitus of patients with myocardial infarction

Objetivo: Determinar si existe alguna relación entre los niveles de antitrombina III y el infarto del miocardio por trombosis coronaria en el paciente diabético no insulinodependiente. Material y métodos: Se realizó un estudio descriptivo en 99 pacientes diabéticos no insulinodependientes. Se midieron niveles plasmáticos de ATIII. En el grupo I se incluyeron 67 de ellos con IM a quienes se les realizó angiografía coronaria. El grupo II se formó con 32 pacientes con DMNID sin infarto del miocardio. Resultados: El grupo I lo integraron 42 pacientes masculinos (63 por ciento) y 25 femeninos (37 por ciento). El intervalo de edades de la población estudiada fue de 42 a 82 años. En la determinación de los niveles de ATIII 50 pacientes (75 por ciento) se encontraron en cifras de referencia (88 a 131 por ciento) y 17 (25 por ciento) con disminución. Los que mostraron nivel de obstrucción coronaria mayor o igual a 85 por ciento fueron 45; de éstos, en 34 (50.7 por ciento) el valor de ATIII se encontró en valores de referencia y en II (16.4 por ciento) con disminución (40 a 83 por ciento). De los 22 con grado de obstrucción menor o igual a 84 por ciento, 16 (24 por ciento) presentaron actividad normal y seis (9 por ciento) mostraron disminución; además, el intervalo de evolución del IM fue de 6 a 60 h, observando que a partir de las 36 h el porcentaje de actividad de la ATIII se encuentra disminuido (40 a 83 por ciento). En el grupo II el porcentaje de actividad de ATIII se encontró dentro de los valores de referencia con un rango de 88 a 115 por ciento. Conclusiones: La actividad de la ATIII no se altera dentro de las primeras 24 h del IM. A pesar de que este estudio no fue diseñado para evaluar la evolución de IM se observó una correlación entre la evolución de éste y la disminución de la actividad de la ATIII

Atherosclerosis and acute arterial thrombosis in rabbits: a model using ballon desendothelization without dietary intervention

Acute thrombosis can be induced in rabbits by a triggering protocol using Russell's viper venom and histamine given after 8 months of a 1 per cent cholesterol diet and balloon desendothelization. In the present study, we tested the hypothesis that aortic desendothelization performed 4 months before the triggering protocol without a high cholesterol diet is a highly effective and less expensive way of producing arterial atherosclerosis and thrombosis. Nineteen male New Zealand white rabbits on a normal diet were studied. The control group (N = 9) received no intervention during the 4-month observation period, while the other group (N = 10) was submitted to aortic balloon desendothelization using a 4F Fogarty catheter. At the end of this period, all animals were killed 48 h after receiving the first dose of the triggering treatment. Eight of 10 rabbits (80 per cent) in the balloon-trauma group presented platelet-rich arterial thrombosis while none of the animals in the control group had thrombus formation (P<0.01). Thus, this model, using balloon desendothelization without dietary manipulation, induces arterial atherosclerosis and thrombosis and may provide possibilities to test new therapeutic approaches.