Impacto da técnica de dissecção/ reentrada anterógrada nas intervenções coronárias percutâneas para oclusão crônica: registro LATAM Chronic Total Occlusion / Impact of antegrade dissection and re-entry technique on coronary percutaneous interventions for chronic total occlusion: the LATAM Chronic Total Occlusion registry

Introdução: As mais novas técnicas de intervenção coronária percutânea em oclusões crônicas podem melhorar o sucesso técnico. Os objetivos deste estudo foram descrever a segurança e a eficácia da técnica de dissecção/reentrada anterógrada como estratégia inicial de revascularização. Métodos: Registro multicêntrico de países latino-americanos (LATAM Chronic Total Occlusion). Analisamos as características iniciais e os desfechos dos casos em que foi empregada dissecção/ reentrada anterógrada como estratégia primária ou de resgate após escalonamento de fios por via anterógrada. Foram excluídos os casos de abordagem retrógrada. Os médicos usaram dissecção anterógrada convencional e técnica de reentrada. Resultados: Dos 1.875 pacientes analisados, em 50 foi planejada a dissecção/reentrada anterógrada, e, em 1.825, foi planejado o escalonamento de fios por via anterógrada primário. Deu-se preferência à dissecção/reentrada anterógrada em pacientes mais idosos e com história de revascularização (revascularização do miocárdio: dissecção/ reentrada anterógrada em 33,3% e escalonamento de fios por via anterógrada primário em 13,4%, com p<0,001; intervenções coronárias percutâneas em 66,6 e 48,8%, respectivamente, com p=0,012). Oclusões crônicas mais longas (30mm [22-41] e 21mm [15-30], p<0,001) e calcificações moderadas ou graves (62 e 42,6%, com p=0,008) foram associadas à seleção da dissecção/reentrada anterógrada primária, ao invés do escalonamento de fios por via anterógrada primário. Houve correlação significativa entre o aumento do escore J-CTO (X2=37, df=5; p<0,001) e o uso da dissecção/ reentrada anterógrada. O escalonamento de fios por via anterógrada primário teve taxa de sucesso de 88,4%, e a dissecção/reentrada anterógrada, de 76,7%. Para o escalonamento de fios por via anterógrada primário e dissecção/reentrada anterógrada de resgate, o uso do dispositivo CrossBoss® foi relacionado às maiores taxas de sucesso (92,3 e 82,7%, respectivamente). Os desfechos a curto prazo foram semelhantes nos grupos. Conclusão: Na América Latina, a técnica de dissecção/ reentrada anterógrada foi segura e efetiva, tanto como estratégia primária quanto de resgate, mesmo quando utilizada em lesões de maior complexidade. O uso de dispositivos específicos foi relacionado a uma maior taxa de sucesso.

Background: The newest techniques of percutaneous coronary interventions for chronic total occlusion may improve technical success. The objectives were to describe safety and efficacy of antegrade dissection and reentry technique as initial revascularization strategy. Methods: A multicenter registry from Latin American countries (LATAM Chronic Total Occlusion). Baseline characteristics and outcomes of cases using antegrade dissection and reentry as primary strategy or bailout of antegrade wire escalation were analyzed. Retrograde approach cases were excluded. Physicians used conventional antegrade dissection and reentry technique. Results: Out of 1,875 patients analyzed, 50 were planned primary antegrade dissection and reentry and 1,825 planned primary antegrade wire escalation. Primary antegrade dissection and reentry was preferred in older patients, with a history of revascularization (coronary artery bypass graft: primary antegrade dissection and reentry in 33.3% and primary antegrade wire escalation in 13.4%; p<0.001; percutaneous coronary interventions in 66.6% and 48.8%, respectively; p=0.012). Longer chronic total occlusions (30mm [22-41] and 21mm [15-30]; p<0.001), moderate or severe calcification (62% and 42.6%; p=0.008) were associated with the selection of primary antegrade dissection and reentry, instead of primary antegrade wire escalation. There was a significant correlation between increasing J-CTO score (X2=37, df=5; p<0.001), and use of primary antegrade dissection and reentry. Primary antegrade wire escalation had a success rate of 88.4%, and primary antegrade dissection and reentry of 76.7%. For primary antegrade wire escalation and bailout antegrade dissection and reentry, the use of the CrossBoss® device was related to the highest rates of success (92.3 and 82.7%, respectively). Short-term outcomes were similar in both groups. Conclusion: In Latin America, antegrade dissection and reentry was safe and effective, both as primary or bailout strategy, even when used for higher complexity lesions. The use of dedicated devices was related to a higher success rate.

Impacto de la técnica de Cusp-Overlap en el requerimiento de marcapasos luego de un implante valvular aórtico percutáneo / Impact of Cusp-Overlap Technique on Pacemaker Requirement after Transcatheter Aortic Valve Implantation

RESUMEN Introducción: Las bradiarritmias persistentes que requieren el implante de un marcapasos definitivo son una complicación frecuente tras el implante valvular aórtico percutáneo (IVAP), pero un implante alto con técnica Cusp-Overlap podría evitar las alteraciones del sistema de conducción. Objetivo: El objetivo fue determinar la tasa de uso de marcapasos en pacientes que recibieron IVAP con la técnica convencional coplanar en comparación con Cusp-Overlap. Material y métodos: Entre 2017 y 2019 se analizaron 65 pacientes consecutivos de dos centros, que recibieron válvulas EvolutR o Evolut-Pro: 50 implante coplanar y 15 Cusp-Overlap. Resultados: La edad promedio era 80 años y no hubo diferencias en el riesgo por puntaje EuroSCORE. Los procedimientos con la técnica de Cusp-Overlap presentaron 0% de requerimiento de marcapasos en comparación con 24,9% en el implante convencional (p = 0,041). También hubo menos complicaciones mayores (6,67% vs 42%; OR = 0,09; IC 95% 0,01-0,8; p = 0,011). Conclusiones: En esta cohorte el IVAP con la técnica de Cusp-Overlap se asoció con una necesidad de marcapasos nula. Dado el potencial impacto a gran escala se necesita validar externamente los resultados obtenidos.

ABSTRACT Background: Persistent bradyarrhythmias requiring permanent pacemaker implantation are a common complication after transcatheter aortic valve implantation (TAVI), but high implantation with cusp-overlap technique could prevent conduction system disturbances. Objective: The aim of this study was to assess the rate of pacemaker use in patients who received TAVI with conventional coplanar technique compared with cusp-overlap technique. Methods: A total of 65 consecutive patients from two centers receiving Evolut-R or Evolut-Pro valve implantation, 50 coplanar and 15 cusp-overlap, were analyzed between 2017 and 2019. Results: Mean age was 80 years, and there were no differences in risk according to the EuroSCORE. The rate of pacemaker requirement was 0% in cusp-overlap procedures compared with 24.9% in those with conventional implantation; p=0.041). In addition, cusp-overlap implants presented lower rate of major complications (6.67% vs. 42%; OR=0.09; 95% CI 0.01-0.8; p=0.011). Conclusions: In this cohort, TAVI procedure with cusp-overlap technique was associated with null pacemaker requirement. Given the potential large-scale impact, external validation of results is needed.

Experiencia multicéntrica de implante valvular aórtico percutáneo discriminada por riesgo en centros de Latinoamérica / Multicenter Experience of Transcatheter Aortic Valve Implantation Stratified by Risk in Latin American Centers

RESUMEN Introducción: El implante valvular aórtico percutáneo ha sido valorado en diferentes escenarios del amplio espectro de la población portadora de estenosis aórtica grave sintomática. La elección del tipo de tratamiento parte de una evaluación del riesgo de un equipo multidisciplinario. Objetivos: El objetivo de este estudio fue analizar las características y conocer los resultados de los pacientes sometidos a IVAP en Latinoamérica según el riesgo. Material y métodos: Se incluyeron a partir de marzo de 2009 a diciembre de 2018 pacientes en forma continua del registro multicéntrico latinoamericano de implante valvular aórtico percutáneo. La indicación de implante valvular aórtico percutáneo fue realizada en cada caso por un equipo multidisciplinario local. Se estratifica la población en función del riesgo quirúrgico evaluado por el puntaje STS-PROM. Se definieron tres grupos en función de los puntos de corte del STS -PROM establecidos: riesgo alto (RA, mayor del 8%), riesgo intermedio (RI, entre el 4% y el 8%) y riesgo bajo (RB, menordel 4%). Resultados: Se incluyeron en el análisis 770 pacientes; la mitad era de sexo femenino (50,2%) con una mediana de edad de 81 años (RIC 75,6-85,7). Del total, 230 pacientes (29,8%) fueron incluidos en el grupo AR (STS-PROM medio 11 [9,3-16,7]); 339 pacientes (44%), al riesgo intermedio (STS-PROM medio 6 [4,8-6,71]); y los restantes 201 (26,1%), al bajo riesgo (STS-PROM medio 2,7 [2-3,24]). La proporción de pacientes de bajo riesgo se incrementó a lo largo del período del registro (ptrend 0,011). Se utilizó acceso femoral (95%), y fue percutáneo en el 69% de los pacientes. Se implantaron en el 80% válvulas autoexpandibles. Del total de válvulas implantadas, el 23% (n = 177) resultaron ser reposicionables sin diferencias a través de los grupos. No se evidenciaron diferencias en mortalidad a los 30 días (RA 10,4%, RI 6,48%, RB 5,9%, p: 0,154) Tanto en el RA como en el de RB se observó una reducción de la mortalidad (RA 13,7%-4,1%, p: 0,001; RB 11,7%-0%; p: 0,0023). Conclusiones: La estratificación de riesgo mediante puntajes quirúrgicos continúa representando una guía de gran utilidad, sin embargo la indicación de implante valvular percutáneo en el mundo real incorpora otros factores no contemplados en la puntuación clásica, que modifica nuestras decisiones en la práctica diaria.

SUMMARY Introduction: Transcatheter aortic valve implantation (TAVI) has been evaluated in different scenarios of the broad spectrum of patients with severe symptomatic aortic stenosis. The choice of treatment starts through a risk assessment guided by a multidisciplinary team. Purpose: The aim of this study was to analyze the population undergoing TAVI in Latin America according to their risk. Methods: From March 2009 to December 2018, consecutive TAVI procedures registered in the Latin American multicenter registry were included. The indication of TAVI was made in each case by a multidisciplinary team set up by each center. The population is stratified according to the surgical risk evaluated by the STS-PROM score. Three groups were defined, based on the established STS-PROM cut-off points: high risk (RA, higher 8%), intermediate risk (IR, between 4%-8%) and low risk (RB, lower 4%). Results: 770 patients were included in the analysis, resulting 50,2% female, with a mean age of 81 y/o (IQR 75.6-85.7). 29.8% were included in the AR group (STS-PROM 11 (9.3-16.7), 44% at intermediate risk (STS-PROM 6 (4.8-6.71) and 26.1% at low risk (STS-PROM 2.7 (2-3.24). The proportion of low-risk patients has increased significantly over the period of inclusion (ptrend 0.011). Femoral access (95%), being percutaneous in 69% of patients. Self-expanding valves were implanted in 80%. 23% of the valves were repositionable without differences across the groups. There was no differences in 30-day mortality (RA 10.4%, IR 6.48%, RB 5.9%, p 0.154). Reduction in mortality were observed (RA 13, 7-4.1%, p0.001; RB 11.7-0%; p 0.0023) during the analyzed period. Conclusions: Risk stratification through surgical "scores" continues to represent a very useful guide, however the indication of TAVI in the real world incorporates other factors not contemplated in the classical score, which modifies our decisions in daily practice.

Problemas y soluciones en la implementación de un Programa de Implante Valvular Aórtico Percutáneo / Problems and Solutions in the Implementation of a Transcatheter Aortic Valve Implantation Program

Introducción La sobrevida de la estenosis aórtica grave sintomática inoperable es baja. El implante percutáneo de válvula aórtica (IVAP) representa una alternativa para estos pacientes. Es nuestra práctica que los candidatos a IVAP ingresen en un programa de evaluación (Programa de IVAP) para determinar su elegibilidad clínica para, luego, solicitar la aprobación a la cobertura de salud. Objetivos Evaluar las causas de la exclusión de pacientes del procedimiento y su impacto clínico. Material y métodos Desde abril de 2009 hasta agosto de 2011, 37 pacientes ingresaron en el Programa de IVAP. Resultados De los 37 pacientes, 29 recibieron el tratamiento o fueron descartados: 14 fueron sometidos a IVAP (grupo IVAP, 48,3%) y 15 fueron descartados (grupo no IVAP 52,7%). Del grupo no IVAP, seis pacientes (40%) fueron descartados por el Programa y cuatro por la cobertura médica, mientras que otros cinco pacientes fallecieron aguardando la autorización. La mediana de EuroSCORE de la población fue del 22% (rango 10-56%) y el promedio de edad fue de 79 ± 8 años. En un seguimiento de 12 meses, la mortalidad del grupo IVAP y no IVAP fue del 7,1% y del 33,3%, respectivamente (p = 0,082). La mortalidad cardiovascular total fue del 17,2%, en todos los casos del grupo no IVAP. Conclusión En nuestro medio, más de la mitad de los pacientes evaluados en un Programa de IVAP no son intervenidos. Razones médicas y socioeconómicas inciden en la toma de decisiones y en la realización o no del IVAP, observándose una mortalidad importante en los pacientes no tratados.

Background Survival of severe symptomatic aortic valve replacement in patients who are not candidates for cardiac surgery is low. Transcatheter aortic valve implantation (TAVI) represents an alternative for these patients. Candidates for TAVI are evaluated in our TAVI Program, firstly to determine if they are clinically eligible and secondly to request the health medical coverage the authorization of the procedure. Objectives To evaluate the reasons for the exclusion of patients from the procedure and its clinical impact. Methods From April 2009 to August 2011, 37 patients were admitted in the TAVI Program. Results From the original 37 patients, 29 were divided into two groups: TAVI group (14 patients undergoing the procedure, 48.3%) and no TAVI group (15 patients rejected for the procedure, 52.7%). In the no TAVI group, six patients (40%) were rejected by the Program and four by the medical coverage, while other five died waiting for the authorization. Median EuroSCORE was of 22% (range 10-56%) and mean age was 79±8 years. After 12 months of follow-up, mortality in the TAVI group and no TAVI group was 7.1% and 33.3%, respectively (p=0.082). Overall cardiovascular mortality was of 17.2%, in all the cases in the no TAVI group. Conclusion In our environment, more than half of the patients evaluated in a TAVI Program do not undergo the procedure. Medical and social and economic reasons influence the decision-making process and carrying out TAVI, with an important mortality in untreated patients.

Problemas y soluciones en la implementación de un Programa de Implante Valvular Aórtico Percutáneo / Problems and Solutions in the Implementation of a Transcatheter Aortic Valve Implantation Program

Introducción La sobrevida de la estenosis aórtica grave sintomática inoperable es baja. El implante percutáneo de válvula aórtica (IVAP) representa una alternativa para estos pacientes. Es nuestra práctica que los candidatos a IVAP ingresen en un programa de evaluación (Programa de IVAP) para determinar su elegibilidad clínica para, luego, solicitar la aprobación a la cobertura de salud. Objetivos Evaluar las causas de la exclusión de pacientes del procedimiento y su impacto clínico. Material y métodos Desde abril de 2009 hasta agosto de 2011, 37 pacientes ingresaron en el Programa de IVAP. Resultados De los 37 pacientes, 29 recibieron el tratamiento o fueron descartados: 14 fueron sometidos a IVAP (grupo IVAP, 48,3%) y 15 fueron descartados (grupo no IVAP 52,7%). Del grupo no IVAP, seis pacientes (40%) fueron descartados por el Programa y cuatro por la cobertura médica, mientras que otros cinco pacientes fallecieron aguardando la autorización. La mediana de EuroSCORE de la población fue del 22% (rango 10-56%) y el promedio de edad fue de 79 ± 8 años. En un seguimiento de 12 meses, la mortalidad del grupo IVAP y no IVAP fue del 7,1% y del 33,3%, respectivamente (p = 0,082). La mortalidad cardiovascular total fue del 17,2%, en todos los casos del grupo no IVAP. Conclusión En nuestro medio, más de la mitad de los pacientes evaluados en un Programa de IVAP no son intervenidos. Razones médicas y socioeconómicas inciden en la toma de decisiones y en la realización o no del IVAP, observándose una mortalidad importante en los pacientes no tratados.(AU)

Background Survival of severe symptomatic aortic valve replacement in patients who are not candidates for cardiac surgery is low. Transcatheter aortic valve implantation (TAVI) represents an alternative for these patients. Candidates for TAVI are evaluated in our TAVI Program, firstly to determine if they are clinically eligible and secondly to request the health medical coverage the authorization of the procedure. Objectives To evaluate the reasons for the exclusion of patients from the procedure and its clinical impact. Methods From April 2009 to August 2011, 37 patients were admitted in the TAVI Program. Results From the original 37 patients, 29 were divided into two groups: TAVI group (14 patients undergoing the procedure, 48.3%) and no TAVI group (15 patients rejected for the procedure, 52.7%). In the no TAVI group, six patients (40%) were rejected by the Program and four by the medical coverage, while other five died waiting for the authorization. Median EuroSCORE was of 22% (range 10-56%) and mean age was 79±8 years. After 12 months of follow-up, mortality in the TAVI group and no TAVI group was 7.1% and 33.3%, respectively (p=0.082). Overall cardiovascular mortality was of 17.2%, in all the cases in the no TAVI group. Conclusion In our environment, more than half of the patients evaluated in a TAVI Program do not undergo the procedure. Medical and social and economic reasons influence the decision-making process and carrying out TAVI, with an important mortality in untreated patients.(AU)

Curva de aprendizaje en el tratamiento percutáneo de las lesiones carotídeas / Learning curve during percutaneous treatment of carotid lesions

Introducción La angioplastia transluminal percutánea (ATP) carotídea con implante de stent es un procedimiento eficaz en la prevención del accidente cerebrovascular (ACV) de tipo isquémico, pero su morbimortalidad periprocedimiento aún es discutida. Objetivo Comunicar los resultados de una serie prospectiva de pacientes tratados con ATP. Material y métodos Estudio descriptivo, observacional y prospectivo de la base de datos de tres centros de Hemodinamia de la Ciudad de Buenos Aires, en el que se incluyeron todos los pacientes sometidos a ATP carotídea desde enero de 1998 a noviembre de 2010. Se analizaron los resultados de las ATP realizadas por un mismo operador. Resultados La edad media fue de 69 años, el 58% de los pacientes eran hombres, el 58,8% tabaquistas, el 52% dislipidémicos, el 79,1% hipertensos y el 28% diabéticos. El 19,4% y el 11,6% tenían historia previa de infarto y cirugía coronaria, respectivamente. Desde 1998 hasta 2004 (etapa inicial, n = 54) hubo un 72% de pacientes sintomáticos con indicación de revascularización; en esta etapa no se utilizó sistema de protección cerebral. En la etapa más contemporánea (2004-2010, n = 171), sólo el 17,5% fueron sintomáticos y el uso de sistema de protección cerebral fue sistemático. Se observó una tasa similar de éxito angiográfico en las dos etapas (inicial 96% vs. contemporánea 97%), en tanto que la tasa de éxito clínico de la etapa contemporánea fue superior a la obtenida en la etapa inicial (96,1% vs. 87%; p = 0,016). No se observaron complicaciones cardiológicas. La tasa de muerte o ACV intrahospitalario fue del 4%, del 4,3% (3/70) en los sintomáticos y del 3,2% (5/155) en los asintomáticos; esta tasa fue mayor en la etapa inicial que en la contemporánea 11,1% (6/54) vs. 1,7% (2/171); p = 0,0028. Conclusión La ATP representa una alternativa terapéutica de aceptable seguridad, siempre que sea realizada por operadores experimentados.

Learning curve during percutaneous treatment of carotid lesions Background Percutaneous transluminal carotid angioplasty (PTCA) with stent implantation is an effective procedure for the prevention of ischemic stroke (IS) but its periprocedural morbimortality is still subject to debate. Objective The aim of this study is to report the results of a prospective series of patients treated with PTCA. Methods This is a descriptive, observational, prospective study using the database of three Hemodynamic centers in Buenos Aires, which included all patients submitted to PTCA from January 1998 to December 2010. The results of PTCA performed by the same operator were analyzed. Results Mean age was 69 years, 58% of the patients were men, 58.8% were smokers, 52% had dyslipidemia, 79.1% were hypertensive, and 28% had diabetes. Prior history of acute myocardial infarction and coronary surgery was present in 19.4 and 11.6% of the patients, respectively. From 1998 to 2004 (initial stage, n=54) 72% of symptomatic patients had indication of revascularization, which was performed without cerebral protection in all cases. During the most recent stage (2004-2010, n=171), only 17.5% of the patients were symptomatic and revascularization was performed systematically with cerebral protection. Similar angiographic success was obtained in both stages (initial 96% vs. recent 97%), whereas clinical success rate was greater in the recent phase (96.1% vs. 87%, p=0.016). There were no cardiac complications. The death rate or intrahospital stroke was 4%, 4.3% (3/70) in symptomatic and 3.2% (5/155) in asymptomatic patients; moreover, this rate was higher in the initial than in the recent phase (11.1% 6/54 vs. 1.7% 2/171, p=0.0028). Conclusions PTCA represents an acceptably safe therapeutic alternative to surgical revascularization, providing the procedure is performed by experienced operators.

Curva de aprendizaje en el tratamiento percutáneo de las lesiones carotídeas / Learning curve during percutaneous treatment of carotid lesions

Introducción La angioplastia transluminal percutánea (ATP) carotídea con implante de stent es un procedimiento eficaz en la prevención del accidente cerebrovascular (ACV) de tipo isquémico, pero su morbimortalidad periprocedimiento aún es discutida. Objetivo Comunicar los resultados de una serie prospectiva de pacientes tratados con ATP. Material y métodos Estudio descriptivo, observacional y prospectivo de la base de datos de tres centros de Hemodinamia de la Ciudad de Buenos Aires, en el que se incluyeron todos los pacientes sometidos a ATP carotídea desde enero de 1998 a noviembre de 2010. Se analizaron los resultados de las ATP realizadas por un mismo operador. Resultados La edad media fue de 69 años, el 58% de los pacientes eran hombres, el 58,8% tabaquistas, el 52% dislipidémicos, el 79,1% hipertensos y el 28% diabéticos. El 19,4% y el 11,6% tenían historia previa de infarto y cirugía coronaria, respectivamente. Desde 1998 hasta 2004 (etapa inicial, n = 54) hubo un 72% de pacientes sintomáticos con indicación de revascularización; en esta etapa no se utilizó sistema de protección cerebral. En la etapa más contemporánea (2004-2010, n = 171), sólo el 17,5% fueron sintomáticos y el uso de sistema de protección cerebral fue sistemático. Se observó una tasa similar de éxito angiográfico en las dos etapas (inicial 96% vs. contemporánea 97%), en tanto que la tasa de éxito clínico de la etapa contemporánea fue superior a la obtenida en la etapa inicial (96,1% vs. 87%; p = 0,016). No se observaron complicaciones cardiológicas. La tasa de muerte o ACV intrahospitalario fue del 4%, del 4,3% (3/70) en los sintomáticos y del 3,2% (5/155) en los asintomáticos; esta tasa fue mayor en la etapa inicial que en la contemporánea 11,1% (6/54) vs. 1,7% (2/171); p = 0,0028. Conclusión La ATP representa una alternativa terapéutica de aceptable seguridad, siempre que sea realizada por operadores experimentados.(AU)

Learning curve during percutaneous treatment of carotid lesions Background Percutaneous transluminal carotid angioplasty (PTCA) with stent implantation is an effective procedure for the prevention of ischemic stroke (IS) but its periprocedural morbimortality is still subject to debate. Objective The aim of this study is to report the results of a prospective series of patients treated with PTCA. Methods This is a descriptive, observational, prospective study using the database of three Hemodynamic centers in Buenos Aires, which included all patients submitted to PTCA from January 1998 to December 2010. The results of PTCA performed by the same operator were analyzed. Results Mean age was 69 years, 58% of the patients were men, 58.8% were smokers, 52% had dyslipidemia, 79.1% were hypertensive, and 28% had diabetes. Prior history of acute myocardial infarction and coronary surgery was present in 19.4 and 11.6% of the patients, respectively. From 1998 to 2004 (initial stage, n=54) 72% of symptomatic patients had indication of revascularization, which was performed without cerebral protection in all cases. During the most recent stage (2004-2010, n=171), only 17.5% of the patients were symptomatic and revascularization was performed systematically with cerebral protection. Similar angiographic success was obtained in both stages (initial 96% vs. recent 97%), whereas clinical success rate was greater in the recent phase (96.1% vs. 87%, p=0.016). There were no cardiac complications. The death rate or intrahospital stroke was 4%, 4.3% (3/70) in symptomatic and 3.2% (5/155) in asymptomatic patients; moreover, this rate was higher in the initial than in the recent phase (11.1% 6/54 vs. 1.7% 2/171, p=0.0028). Conclusions PTCA represents an acceptably safe therapeutic alternative to surgical revascularization, providing the procedure is performed by experienced operators.(AU)

Reemplazo percutáneo de la válvula aórtica en pacientes con estenosis aórtica grave y riesgo quirúrgico elevado / Percutaneous Aortic Valve Replacement in Patients with Severe Aortic Stenosis and High Surgical Risk / Percutaneous Aortic Valve Replacement in Patients with Severe Aortic Stenosis and High Surgical Risk

Introducción La cirugía de reemplazo valvular aórtico es el tratamiento de elección en pacientes con estenosis aórtica. Sin embargo, en una proporción considerable de pacientes, el riesgo quirúrgico y la presencia de algunas comorbilidades, que aumentan este riesgo, impiden la cirugía. El reemplazo percutáneo de la válvula aórtica representa una alternativa a la cirugía valvular convencional para pacientes seleccionados de riesgo elevado. Objetivo Comunicar la experiencia inicial de reemplazo percutáneo de la válvula aórtica con prótesis autoexpandible CoreValve® (Medtronic, Minneapolis, MN, USA) en pacientes portadores de estenosis aórtica grave. Material y métodos Registro multicéntrico en el que se incluyeron 21 pacientes con estenosis aórtica grave (área < 1 cm²) sintomática y riesgo quirúrgico elevado sometidos a implante percutáneo en cuatro centros cardiovasculares argentinos de alta complejidad. Para el procedimiento se implementó una estrategia multidisciplinaria que involucró a diversos especialistas: anestesiólogo, cirujano, expertos en imágenes y cardiólogos intervencionistas. Resultados La edad media fue de 80,8 ± 7,1 años (rango: 63-90), el 57% de sexo masculino, área valvular media de 0,59 ± 0,25 cm² y EuroSCORE de 18,1% ± 4%. El 73% y el 27% de los pacientes se encontraban en clase funcional III y IV, respectivamente. El éxito del procedimiento fue del 95,2% (20/21), que se tradujo en una reducción pronunciada del gradiente pico transvalvular aórtico (82 ± 14 mm Hg a 12 ± 3 mm Hg; p < 0,001), mientras que el desarrollo posprocedimiento de regurgitación aórtica de grado moderado-grave fue del 14%. El 85,8% de los pacientes evolucionaron a clase funcional I. El requerimiento de marcapasos definitivo fue del 38% (8/21). La mortalidad del procedimiento y a los 30 días fue del 4,7% y del 9,5%, respectivamente; se observó un caso de accidente cerebrovascular isquémico menor con restitución ad integrum dentro de la semana. Se detectaron 4 óbitos en el seguimiento alejado (mediana 7 meses), dos de origen cardíaco (mortalidad cardíaca 19%) y otros dos de causa no cardíaca. Conclusiones El tratamiento de la estenosis aórtica grave en pacientes de riesgo quirúrgico elevado mediante reemplazo valvular percutáneo con prótesis CoreValve® es una alternativa factible que se asocia con una mejoría funcional notoria. La selección adecuada de pacientes, el perfeccionamiento de la técnica del procedimiento y el desarrollo de nuevos diseños incrementarán su eficacia y seguridad.

Background Aortic valve replacement is the treatment of choice in patients with aortic stenosis. However, a significant number of patients are not candidates for surgery due to high surgical risk and to the presence of comorbidities. Percutaneous aortic valve replacement represents an alternative option to conventional aortic valve surgery for selected high risk patients. Objective To inform about the initial experience with percutaneous aortic valve replacement with a self-expanding CoreValve® aortic valve prosthesis (Medtronic, Minneapolis, MN, USA). Material and Methods We conducted a multicenter registry including 21 patients with severe symptomatic aortic stenosis (aortic valve area < 1 cm²) and high surgical risk undergoing percutaneous aortic valve replacement in four high complexity cardiovascular centers. A multidisciplinary strategy was used involving several specialists: anesthesiologist, surgeon, diagnostic images specialists and interventional cardiologists. Results Mean age was 80.8±7.1 years (range: 63-90); 57% were men. Mean aortic valve area was 0.59±0.25 cm² and mean EuroSCORE was 18.1%±4%. The percentages of patients in functional class III and IV were 73% and 27%, respectively. The procedure was successful in 95.2% (20/21) of patients, with a pronounced reduction in peak transvalvular aortic gradient (from 82±14 mm Hg to 12±3 mm Hg; p <0,001); 14% of patients developed moderate to severe aortic regurgi-tation after the procedure. 85.5% of patients evolved to FC I. Definite pacemaker implantation was required in 38% (8/21). Procedure-related mortality was 4.7% and mortality after 30 days was 9.5%. One patient developed a minor stroke with complete recovery within a week. Four patients died in the long-term follow-up (median 7 months): 2 due to cardiac causes (cardiac mortality 19%) and 2 due to non-cardiac causes. Conclusions Percutaneous aortic valve replacement with CoreValve® aortic valve prosthesis is a feasible option for patients with high surgical risk that is associated with significant clinical improvement. The adequate selection of patients, improvement of the surgical technique and the development of new designs will increase the efficacy and safeness of the procedure.

Accuracy of low-dose prospectively gated axial coronary CT angiography for the assessment of coronary artery stenosis in patients with stable heart rate.

BACKGROUND: Desirable methods for cardiac CT angiography would both reduce radiation exposure from cardiac CT angiography and preserve accuracy. OBJECTIVES: We assessed image quality, radiation dose, and diagnostic accuracy of a low-dose, prospectively gated axial cardiac CT angiography protocol for the evaluation of patients with suspected coronary artery disease (CAD). METHODS: Fifty consecutive patients referred for diagnostic invasive coronary angiography (ICA) and with a stable heart rate < 60 beats/min after beta-blocker administration were prospectively enrolled in a single center study. Subjects underwent CT angiography with a 64-row multidetector CT scanner with a prospectively gated axial imaging protocol. If the examination was determined to be nondiagnostic, then a retrospectively gated helical scan was performed. Two reviewers independently assessed image quality and the presence of significant coronary artery stenosis (>50%). RESULTS: Prospectively gated CT angiography was successfully performed in 46 of 50 patients. Of 794 coronary segments, 777 were determined to be of diagnostic image quality. The overall patient-based sensitivity (95% CI), specificity, positive predictive value, negative predictive value, and accuracy for the diagnosis of significant coronary stenosis were 100% (87%-100%), 75% (53%-90%), 81% (64%-93%), 100% (81%-100%), and 88% (81%-95%), respectively. The mean effective radiation dose for CT angiography and ICA were 3.4 +/- 0.4 mSv and 6.9 +/- 0.8 mSv, respectively. CONCLUSIONS: Cardiac CT angiography performed in a prospectively gated axial mode with 64-row multidetector CT provides an accurate, low-dose alternative for the detection of CAD.

Feasibility of 64-slice gadolinium-enhanced cardiac CT for the evaluation of obstructive coronary artery disease.

OBJECTIVE: To assess the feasibility of gadolinium-enhanced 64-slice cardiac CT (CCT) for the diagnosis of obstructive coronary artery disease. DESIGN: Comparative prospective study. SETTING: Outpatient Imaging Diagnostic Centre, Diagnóstico Maipú, Buenos Aires, Argentina. PATIENTS: Twenty patients with suspected coronary artery disease. INTERVENTIONS: Gadolinium-enhanced 64-slice CCT was performed before invasive coronary angiography (ICA). MAIN OUTCOME MEASURES: The feasibility of gadolinium-enhanced 64-slice CCT for detection of obstructive coronary artery disease (>50% diameter reduction) was evaluated, using ICA as the 'gold standard'. Mean lumen attenuation, non-calcified and calcified plaques densities were correlated between gadolinium-enhanced CCT studies and iodine-enhanced CCT studies of a control group. Renal function was strictly monitored. RESULTS: Gadolinium-enhanced CCT demonstrated adequate visualisation of 283/289 coronary segments that were evaluable by ICA, 31 of which had >50% luminal stenosis. In per-segment analysis, gadolinium-enhanced CCT showed a sensitivity of 90.3%, specificity of 96.8%, positive predictive value of 77.8% and negative predictive value of 98.8%. The agreement of coronary stenosis between multidetector CT (MDCT) and ICA was 94.1% (272/289). The mean lumen attenuation, non-calcified and calcified plaques densities in gadolinium-enhanced CCT studies were 140.1 Hounsfield units (HU), 51.1 HU and 523.6 HU, whereas in iodine-enhanced CCT studies the values were 354.1 HU, 101.0 HU and 778.5 HU, respectively (p < 0.001). CONCLUSION: Gadolinium-enhanced CCT is a feasible alternative for patients with severe contraindications to iodinated contrast agents referred for MDCT coronary angiography.

Reubicación de los vasos del cuello y exclusión endovascular de las disecciones y los aneurismas del arco aórtico / Replacement of Neck Vessels and Endovascular Exclusion of Aortic Arch Dissections and Aneurysms

El tratamiento endovascular de la aorta descendente le brinda a un grupo de pacientes seleccionados de alto riesgo una alternativa para resolver un problema grave de manera segura y efectiva. Sólo el 15% de los enfermos tiene un cuello adecuado para el implante respetando la integridad de la arteria subclavia izquierda y su oclusión intencional origina en hasta un 30% isquemia del brazo, síndrome vertebrobasilar o leaks. Además, los pacientes que presentan compromiso del arco aórtico (extensión retrógrada de la disección, porque ésta se origina allí o por aneurisma de ese sector) constituyen una población aún más seleccionada y de mayor riesgo para el tratamiento quirúrgico habitual. Entre noviembre de 2005 y diciembre de 2006 incluimos 10 pacientes que se presentaban con: 1) disecciones con compromiso de la arteria subclavia izquierda o retrodisecciones hacia el cayado aórtico (n = 7) y 2) aneurismas del cayado aórtico (n = 3). Fueron tratados dentro del período agudo (14 días), todos con un puntaje de riesgo anestésico (ASA) igual a 3 o mayor. Se utilizó una técnica híbrida, de un solo acto en dos etapas (quirúrgica/endovascular) realizadas en el mismo día. En la fase quirúrgica no se requirió paro cardíaco, circulación extracorpórea ni hipotermia profunda y durante la etapa endovascular se utilizaron prótesis autoexpandibles y es aquí donde se notaron las dificultades técnicas que debieron sortearse para llevar adelante el implante. Todos los procedimientos resultaron técnicamente exitosos. Dos pacientes fallecieron, uno en el primer día (taponamiento cardíaco) otro por sepsis en el día 27. No se registraron complicaciones neurológicas ni vasculares. La técnica fue factible y efectiva, con una morbimortalidad adecuada para la población en estudio y similar a la de publicaciones con pacientes de las mismas características.

Endovascular treatment of the descendant aorta is a safe and effective alternative to solve a severe condition in a selected group of high-risk patients. In only 15% of patients the anatomical relations of the aneurysm neck with the left subclavian artery are adequate for the implant, and the incidence of arm ischemia, vertebrobasilar artery syndrome or leaks related to the left subclavian artery intentionally occluded reaches 30%. In addition, patients with compromise of the aortic arch (due to dissections or aneurysms of the aortic arch) are still a more selected high-risk population for surgical treatment. Between November 2005 and December 2006 we included 10 patients with: 1) dissections with compromise of the left subclavian artery or dissections towards the aortic arch (n=7) and, 2) aneurisms of the aortic arch (n=3). All patients had ASA class III or greater, and they were all treated during the acute phase (14 days). A two-stage (surgical/endovascular) hybrid technique was performed during the same day. The surgical approach was carried out without the need for circulatory arrest, extracorporeal circulation, and deep hypothermia, but endovascular self-expanding stent-graft placement presented a few technical difficulties. All procedures were technically successful. Two patients died, one at day 1 (cardiac tamponade) and the other at day 27 (sepsis). No neurologic or vascular complications were reported. The procedure was feasible and effective, with morbidity and mortality rates according to the study population and similar to those reported in other studies performed on comparable patients.

Evaluación de las placas coronarias por tomografía computarizada multidetector de 16 filas: Correlación con ecografía intravascular / Assessment of Coronary Plaques by 16-Row Multidetector Computed Tomography: Correlation with Intravascular Ultrasound

Introducción El 50% de las muertes de etiología cardiovascular se deben a la enfermedad arteriosclerótica. Estudios recientes demostraron que las placas ateromatosas más propensas al desarrollo de un evento coronario son las que presentan ciertas características particulares, como un centro o core lipídico y remodelación positiva, denominadas placas vulnerables. La determinación temprana de la presencia de este tipo de placas ateroscleróticas tendría un impacto clínico de suma importancia y podría ayudar a prevenir el desarrollo de un síndrome coronario agudo en el futuro. Objetivo Determinar la certeza diagnóstica de la angiografía coronaria por tomografía computarizada multidetector de 16 filas (16-ACTCM) en la identificación, la caracterización y la cuantificación de las lesiones arterioscleróticas coronarias en comparación con la ecografía intravascular (EIV). Material y métodos Se estudiaron 45 pacientes con indicación de angiografía coronaria con 16-ACTCM y EIV. En cada segmento coronario se analizaron la carga de placa y las características de la placa aterosclerótica, que se clasificó en blanda, fibrosa y cálcica. La certeza diagnóstica de la 16- ACTCM para determinar la carga de placa y la identificación de placas coronarias se calculó con el método exacto binomial. Sobre la base de un análisis con curvas ROC se determinó el punto de corte para cada tipo de placa, así como la densidad media y la desviación estándar en unidades Hounsfield [UH]). Se evaluó además la certeza diagnóstica de la ACTCM para el diagnóstico de estenosis coronaria ≥ 50%. Resultados Para la detección de carga de placa, la sensibilidad fue del 96,2% y la especificidad fue del 81,9%. Para la detección de placas blandas, fibrosas y calcificadas, la sensibilidad y la especificidad fueron del 94,6% y 92,62%, del 94,9% y 98,5% y del 93,2% y 95,1%, respectivamente. Con un valor de corte de 85 UH, la 16-ACTCM diferenció correctamente el 86% de las placas blandas y fibrosas, con un área ROC = 0,96; con un valor de corte de 196,7 UH diferenció correctamente el 93% de las placas calcificadas y no calcificadas, con un área ROC = 0,98. Para la detección de estenosis coronaria, la sensibilidad fue del 81,58% y la especificidad fue del 93,8%. Conclusión La 16-ACTCM es una modalidad diagnóstica no invasiva promisoria para el estudio de pacientes con enfermedad coronaria, ya que permite la detección y la caracterización de los diferentes tipos de placa.

Background Atherosclerosis counts for 50% of cardiovascular deaths. Recent studies have demonstrated that certain atheromatous plaques with a lipid core and positive remodeling, known as vulnerable plaques, are more likely to develop plaque disruption, resulting in a coronary event. The early identification of these atheromatous plaques would have an extremely important clinical impact and might help to prevent the further development of an acute coronary syndrome. Objective To assess the diagnostic accuracy of coronary angiography with 16-row multidetector computed tomography (16-MCT) for the detection, characterization and quantification of atherosclerotic coronary artery lesions compared to intravascular ultrasound (IVUS). Material and Methods Forty five patients eligible to coronary angiography underwent 16-MCT and IVUS. Plaque burden and the characteristics of atheromatous plaques were analyzed in each coronary segment; plaques were classified in soft, fibrous and calcified. The binomial exact method was used to calculate the diagnostic accuracy of 16-MCT to determine the plaque burden and to identify coronary plaques. ROC curves analysis determined the cut-point for each type of plaque, as well as the mean density and the standard deviation expressed in Hounsfield units (HU). The diagnostic accuracy of the method for the diagnosis of coronary stenosis ≥ 50% was also assessed. Results The sensitivity and specificity of 16-MCT to detect plaque burden were 96.20% and 81.96%, respectively. For the detection of soft, fibrous and calcified plaques, the sensitivity and the specificity were 94.59% and 92.62%, 94.91% and 98.56%, and 93.22% and 95.13%, respectively. Using a cutpoint of 85 HU, 16-MCT properly identified 86% of soft and fibrous plaques, with an area under the ROC curve of 0.96; a cut-point of 196.68 UH resulted in an identification of 93% of calcified and non-calcified plaques, and the area under the ROC curve was 0.98. The sensitivity and specificity of the test for detecting coronary stenosis were 81.58% and 93.86%, respectively. Conclusion 16-MCT is a promising non-invasive diagnostic tool for the assessment of patients with coronary artery disease, useful for the detection and characterization of the different types of plaques.

New approach to noninvasive coronary angiography by multidetector computed tomography: initial experience using gadolinium.

OBJECTIVE: To investigate the gadolinium performance for 16-detector-row coronary computed tomography (CT) angiography. METHODS: Ethics committee approval and informed consent were obtained. Ten patients with coronary artery disease underwent digital coronary angiography and gadolinium-enhanced CT coronary angiography (Gd-CTCA) within the same week. For the Gd-CTCA, each patient received a dose of 0.3 mmol/kg of body weight of 0.5 mmol/mL gadoterate meglumine. Two readers interpreted the CT angiographies independently, and their results were matched with the digital angiography findings. The diagnostic accuracy of Gd-CTCA was calculated by the exact binomial method. RESULTS: Sensitivity, specificity, and positive and negative predictive values were for observer 1: 91.67%, 98.73%, 84.62%, and 99.36%, and for observer 2: 83.33%, 98.73%, 83.33%, and 98.73%, respectively. CONCLUSION: Preliminary results demonstrated that gadolinium chelates may be used as an alternative CT contrast media in coronary CT angiographies, without detriment to diagnosis results.

Feasibility of gadolinium-diethylene triamine pentaacetic acid enhanced multidetector computed tomography for the evaluation of coronary artery disease.

BACKGROUND: Multidetector computed tomography (MDCT) has been proposed as a noninvasive method for the diagnosis of obstructive coronary artery disease (CAD). In patients with high risk of iodinated contrast adverse effects such as acute allergic-type reactions, the use of gadolinium could be an alternative. OBJECTIVE: We sought to evaluate the feasibility of gadolinium-enhanced MDCT for the diagnosis of obstructive CAD. METHODS: Twenty patients (mean age, 61 years; range, 50-73 years) referred for X-ray coronary angiography were studied by both gadolinium and iodine-enhanced 16-row MDCT coronary angiography. The degree of enhancement and the accuracy for detection of obstructive CAD (>50% diameter reduction) were evaluated with X-ray coronary angiography as the standard. Renal nephrotoxicity was strictly monitored. RESULTS: Gadolinium- and iodine-enhanced MDCT showed adequate visualization of the coronary arteries in 310 of the 312 coronary artery segments that were available by X-ray angiography, respectively. The average density of the coronary arteries in both iodine and gadolinium CT scans was 253.65 Hounsfield unit (HU) and 135.20 HU, respectively. In a per-coronary segment analysis, gadolinium- and iodine-enhanced MDCT showed sensitivities of 89% vs 84%, specificities of 96% vs 95%, and negative predictive values of 97% vs 96%, respectively. In a per-patient analysis, both gadolinium- and iodine-enhanced MDCT showed sensitivities of 92.85% vs specificities of 83.33%. Intermethod agreement between gadolinium- and iodine-enhanced MDCT (kappa) was 0.95 (P < 0.0001). CONCLUSION: Our preliminary results indicate lower attenuation with gadolinium but similar diagnostic accuracy for the detection of obstructive CAD when compared with iodine-enhanced MDCT. Therefore, gadolinium is a feasible alternative contrast agent for patients with iodine contrast allergy referred for MDCT coronary angiography.

Tratamiento de un aneurisma coronario con angioplastia transluminal coronaria e implante de un stent cubierto con vena autóloga / Treatment of a coronary aneurysm with angioplasty and implantation of a stent covered with an autologous vein

Se presenta el caso de una mujer de 49 años, con angor en clase funcional II y pruebas provocadoras de isquemia positivas, a la que se detectó un aneurisma en el tercio proximal de la arteria descendente anterior, sin estenosis asociada. Debido a las comunicaciones de la literatura que aconsejan un tratamiento intervencionista cuando estas formaciones se ponen de manifiesto, se le efectuó el implante de un stent cubierto con vena con el fin de excluir la formación y así evitar la trombosis y la embolia, con resultado satisfactorio. Presentamos una descripción detallada de la técnica utilizada. Se destaca la baja incidencia de los aneurismas en la circulación coronaria y la probabilidad de que no se deban a enfermedad arteriosclerótica

Tratamiento de un aneurisma coronario con angioplastia transluminal coronaria e implante de un stent cubierto con vena autóloga / Treatment of a coronary aneurysm with angioplasty and implantation of a stent covered with an autologous vein

Se presenta el caso de una mujer de 49 años, con angor en clase funcional II y pruebas provocadoras de isquemia positivas, a la que se detectó un aneurisma en el tercio proximal de la arteria descendente anterior, sin estenosis asociada. Debido a las comunicaciones de la literatura que aconsejan un tratamiento intervencionista cuando estas formaciones se ponen de manifiesto, se le efectuó el implante de un stent cubierto con vena con el fin de excluir la formación y así evitar la trombosis y la embolia, con resultado satisfactorio. Presentamos una descripción detallada de la técnica utilizada. Se destaca la baja incidencia de los aneurismas en la circulación coronaria y la probabilidad de que no se deban a enfermedad arteriosclerótica (AU)