The clinical value of quantitative cardiovascular molecular imaging: a step towards precision medicine.

Cardiovascular diseases (CVD) are the leading cause of death worldwide and have an increasing impact on society. Precision medicine, in which optimal care is identified for an individual or a group of individuals rather than for the average population, might provide significant health benefits for this patient group and decrease CVD morbidity and mortality. Molecular imaging provides the opportunity to assess biological processes in individuals in addition to anatomical context provided by other imaging modalities and could prove to be essential in the implementation of precision medicine in CVD. New developments in single-photon emission computed tomography (SPECT) and positron emission tomography (PET) systems, combined with rapid innovations in promising and specific radiopharmaceuticals, provide an impressive improvement of diagnostic accuracy and therapy evaluation. This may result in improved health outcomes in CVD patients, thereby reducing societal impact. Furthermore, recent technical advances have led to new possibilities for accurate image quantification, dynamic imaging, and quantification of radiotracer kinetics. This potentially allows for better evaluation of disease activity over time and treatment response monitoring. However, the clinical implementation of these new methods has been slow. This review describes the recent advances in molecular imaging and the clinical value of quantitative PET and SPECT in various fields in cardiovascular molecular imaging, such as atherosclerosis, myocardial perfusion and ischemia, infiltrative cardiomyopathies, systemic vascular diseases, and infectious cardiovascular diseases. Moreover, the challenges that need to be overcome to achieve clinical translation are addressed, and future directions are provided.

[15O]H2O PET: Potential or Essential for Molecular Imaging?

Imaging water pathways in the human body provides an excellent way of measuring accurately the blood flow directed to different organs. This makes it a powerful diagnostic tool for a wide range of diseases that are related to perfusion and oxygenation. Although water PET has a long history, its true potential has not made it into regular clinical practice. The article highlights the potential of water PET in molecular imaging and suggests its prospective role in becoming an essential tool for the 21st century precision medicine in different domains ranging from preclinical to clinical research and practice. The recent technical advances in high-sensitivity PET imaging can play a key accelerating role in empowering this technique, though there are still several challenges to overcome.

Impacto de la diabetes mellitus en pacientes tratados con angioplastia coronaria / Impact diabetes mellitus in patients undergoing percutaneous coronary intervention

RESUMEN Introducción: La diabetes mellitus (DM) se ha asociado a un incremento en los resultados adversos en pacientes tratados con angioplastia coronaria (ATC), en comparación con los pacientes no diabéticos. Objetivos: Evaluar el riesgo de eventos cardiovasculares mayores en los pacientes diabéticos, estratificados según el tratamiento recibido (no insulinorrequirientes o insulinorrequirientes), en una población de pacientes no seleccionada tratados con angioplastia coronaria. Material y métodos: Análisis de registro, unicéntrico y retrospectivo de pacientes con enfermedad coronaria tratados con ATC desde marzo 2009 a junio 2018, según la presencia de DM estratificada de acuerdo con el tratamiento establecido para el control del desorden metabólico en: DM insulino-requirientes (DM-IR) y DM no insulino-requirientes (DM-NIR). Se aplicó un modelo de regresión de Cox ajustado para evaluar la relación entre la presencia de diabetes y el riesgo de eventos cardiovasculares mayores. Resultados: Se incluyeron 6.313 pacientes (seguimiento promedio 4,1 ± 1,8 años), con una prevalencia global de DM del 22,8% (DM-NIR 19,1%; DM-IR 3,8%). Los pacientes diabéticos presentaron un perfil de riesgo elevado, particularmente los DM-IR. Al seguimiento promedio, el riesgo ajustado de eventos cardiovasculares mayores fue similar entre los pacientes No-DM y los DM-NIR (HR 1,02 [0,81-1,27], p 0,85). En relación con los pacientes DM-IR, se observó un riesgo elevado comparados con los No-DM (HR 1,73 [1,20-2,49], p 0,003) y con los DM-NIR (HR 1,65 [1,10-2,48], p 0,015). Se observó una interacción significativa entre el estado diabético y el riesgo de eventos según la indicación de la angioplastia coronaria al ingreso (pint 0,045). Conclusiones: En nuestra serie de pacientes tratados con angioplastia coronaria y con seguimiento a largo plazo, los pacientes diabéticos presentaron alto riesgo de eventos cardiovasculares mayores. Este riesgo se observó particularmente incrementado en pacientes DM-IR. Sin embargo, no se evidenciaron diferencias significativas en el riesgo de eventos entre los pacientes DM-NIR y los No-DM.

ABSTRACT Background: Diabetes mellitus (DM) has been associated with an increase in adverse outcomes in patients treated with coronary angioplasty, compared to non-diabetic patients. Objective: To evaluate the risk of major adverse cardiovascular events in diabetic patients, stratified according to the treatment (non-insulin dependent or insulin-dependent), in a population of unselected patients treated with coronary angioplasty. Methods: Registry-based analysis of patients with coronary artery disease undergoing percutaneous coronary intervention from March 2009 to June 2018, according presence of DM stratified according to the established treatment for the metabolic disorder: insulin-dependent DM (ID -DM) and non-insulin dependent DM (NID -DM). An adjusted Cox regression model was applied to evaluate the relationship between the diabetic status and the risk of major adverse cardiovascular events. Results: A total of 6313 patients were included (mean follow-up 4.1 ± 1.8 years), with a global prevalence of DM of 22,8% (non-insulin dependent DM 19,1%, insulin-dependent DM 3,8%). Diabetic patients showed a higher risk profile, particularly those with ID-DM. At the average follow-up, the adjusted risk of MACE was similar between Non-DM patients and the NIR-DM patients (HR 1,02 [0,81-1,27], p 0.85). In relation to DM-IR patients, it was observed a higher risk of MACE in comparison to Non-DM (HR 1,73 [1,20-2,49], p 0.003) and NIR-DM (HR 1,65 [1,10-2,48], p 0.015). A significant interaction was observed between the diabetic status and the risk of MACE according to the indication of the percutaneous coronary artery intervention (pint 0.045). Conclusions: In our registry of patients undergoing PCI, with long-term follow-up, DM patients had a higher risk of MACE. The risk of MACE was particularly increased in ID-DM patients. However, there were no significant differences in the risk of MACE between DM-NIR and non-DM patients.

Eficiencia y seguridad del acceso radial versus el acceso femoral en la angioplastia coronaria / Efficiency and Safety of Radial Access versus Femoral Access in Percutaneous Coronary Intervention

RESUMEN Introducción: El acceso radial se ha asociado a numerosos beneficios en angioplastia coronaria en comparación con el acceso femoral. Sin embargo, múltiples registros internacionales han reportado una escasa adherencia a esta técnica. Objetivos: Evaluar la seguridad, la eficacia y la eficiencia operativa de la angioplastia coronaria según la vía de acceso utilizada y el cuadro clínico del paciente. Métodos: Análisis de registro, unicéntrico y retrospectivo de los pacientes con enfermedad coronaria tratados con angioplastia coronaria desde marzo de 2009 a junio de 2018, según el acceso vascular. Se aplicó un modelo de regresión de Cox ajustado para evaluar la relación entre la vía de acceso y el riesgo de eventos cardiovasculares mayores y un modelo de regresión logística para evaluar la relación con el sangrado mayor y las complicaciones del acceso vascular. La eficiencia operativa se evaluó mediante la medición del tiempo de internación total y los costos totales asociados a esta. Resultados: Se incluyeron 8155 angioplastias coronarias (seguimiento promedio 1448,6 ± 714,1 días), mediante acceso radial (n = 5706) o acceso femoral (n = 2449). A los 30 días, el riesgo de eventos cardiovasculares mayores se redujo significativamente con el acceso radial (HR 0,66 [0,5-0,88], p = 0,004), a expensas de una reducción de la mortalidad total. A su vez, el acceso radial redujo significativamente el riesgo de sangrado mayor (HR 0,33 [0,16- 0,67], p = 0,002) y de complicaciones del acceso vascular (HR 0,72 [0,53-0,98], p = 0,038). Se observó una interacción significativa entre la vía de acceso y el riesgo de eventos según el cuadro clínico al ingreso. Se observó una reducción significativa del tiempo total de internación (≈30%) y de sus costos totales (≈15%) mediante el uso del acceso radial. Conclusiones: El uso del acceso radial en angioplastia coronaria es seguro y eficaz en comparación con el acceso femoral, con menores tasas de eventos cardiovasculares mayores a los 30 días, como, así también, un menor riesgo de sangrado mayor y complicaciones del acceso vascular. Asimismo, el acceso radial se asoció con una mayor eficiencia operativa durante la internación.

ABSTRACT Background: Radial access has been associated with many advantages in percutaneous coronary intervention compared with femoral access. However, many international registries have reported poor adherence to this technique. Objectives: The aim of this study was to evaluate the safety, efficacy and operational efficiency of percutaneous coronary intervention according to the access site and the clinical presentation of the patient. Methods: A single-center, retrospective registry of patientis with coronary artery disease undergoing percutaneous coronary intervention was conducted from March 2009 to June 2018 according to the vascular access. A Cox proportional-hazards model was used to analyze the association between vascular access and risk of major cardiovascular eventis, and a logistic regression model was applied to assess the relationship between major bleeding and access site complications. Total hospital stay and total hospitalization costis were measured to evaluate the operational efficiency. Resultis: A total of 8,155 percutaneous coronary interventions (mean follow-up of 1,448.6±714.1 days), via radial access (n=5,706) or femoral access (n=2,449), were included in the study. At 30 days, the risk of major cardiovascular eventis was significantly lower with the radial access (HR 0.66 [0.5-0.88], p=0.004), at the expense of a reduction in all-cause mortal-ity In addition, radial access significantly reduced the risk of major bleeding (HR 0.33 [0.16-0.67], p=0.002) and access site complications (HR 0.72 [0.53-0.98], p=0.038). A significant interaction was observed between the vascular access site and the risk of eventis according to the clinical presentation at admission. Use of radial access was associated with a significant reduction in the length of total hospital stay (≈30%) and total hospitalization costis (≈15%). Conclusions: The use of radial access in percutaneous coronary intervention was safe and effective compared with the femoral access, with lower rates of major cardiovascular eventis at 30 days, lower risk of major bleeding and of access site complications. Moreover, radial access was associated with greater operational efficiency during hospitalization.

Eficacia y seguridad del implante valvular aórtico percutáneo por vía transfemoral bajo anestesia general vs. anestesia local más sedación consciente / Efficacy and Safety of Transfemoral Transcatheter Aortic Valve Replacement under General Anesthesia versus Local Anesthesia with Conscious Sedation

RESUMEN: Introducción: Actualmente no hay consenso sobre el manejo anestésico más adecuado en el implante valvular aórtico percutáneo por vía transfemoral. Aunque se ha demostrado la factibilidad de concretar el procedimiento bajo anestesia local con sedación consciente o sin esta, los resultados clínicos reportados son controvertidos. Objetivos: Evaluar la seguridad y eficacia del implante valvular aórtico percutáneo por vía transfemoral realizado bajo anestesia general versus anestesia local con sedación consciente. Material y métodos: Análisis unicéntrico y retrospectivo de los pacientes con estenosis aórtica grave sintomática con alto riesgo quirúrgico sometidos a un implante valvular aórtico percutáneo por vía transfemoral desde marzo de 2009 a diciembre de 2016, según el manejo anestésico. Los desenlaces de seguridad y eficacia fueron evaluados a 30 días según las definiciones del Valve Academic Research Consortium-2. Además, se evaluaron los principales tiempos durante la internación. Resultados: Se incluyeron 121 pacientes (Edad 83,2 ± 5,7 años, hombres 48,8%), tratados con un implante valvular aórtico percutáneo por vía transfemoral bajo anestesia general (n = 55, 45,5%) o anestesia local con sedación consciente (n = 66, 54,5%). No se observaron diferencias significativas en los resultados intraprocedimiento ni en los desenlaces de seguridad y eficacia a 30 días. La mortalidad a 30 días fue del 7,3% en el grupo AG y del 3% en el grupo anestesia local con sedación consciente 3%, p log-rank 0,28 (mortalidad global 5%). La necesidad de conversión a anestesia general se presentó en 2 pacientes (3%), por complicaciones vasculares mayores durante el procedimiento. El grupo anestesia local con sedación consciente presentó menor tiempo total de procedimiento, internación en unidad de cuidados intensivos e internación total. Conclusión: El implante valvular aórtico percutáneo por vía transfemoral realizado bajo anestesia local con sedación consciente, parece ser una alternativa segura y eficaz al uso de anestesia general.

Abstract: Background: Currently, there is no consensus about the most adequate anesthetic management in transfemoral transcatheter aortic valve replacement. Although it has been shown that local anesthesia (LA) with or without conscious sedation is feasible, clinical results are controversial. Objective: The aim of this study was to evaluate the safety and efficacy of transfemoral transcatheter aortic valve replacement performed under general anesthesia versus local anesthesia with conscious sedation. Methods: This was a single-center, retrospective study of high risk patients with severe aortic stenosis undergoing transfemoral transcatheter aortic valve replacement between March 2009 and December 2016. The population was divided according to anesthetic management. Safety and efficacy outcomes were evaluated at 30-days and were classified according to definitions of the Valve Academic Research Consortium-2. In addition, key times during hospitalization were evaluated. Results: A total of 121 patients undergoing transfemoral transcatheter aortic valve replacement under general anesthesia (n=55, 45.5%) or local anesthesia with conscious sedation (n=66, 54.5%). were included in this analysis. Mean age was 83.2±5.7 years and 48.8% were men. There were no differences in either the procedural result or in the 30-day efficacy and safety outcomes. The rate of death at 30-days was 7.3% in the group with general anesthesia and 3% in the local anesthesia with conscious sedation group (log-rank p 0.28). The need of conversion to general anesthesia was 3% (2 patients), in all cases due to major vascular complications during the procedure. In the local anesthesia with conscious sedation group shorter procedural time, intensive care unit and hospital length of stay were observed. Conclusions: Transfemoral transcatheter aortic valve replacement performed under local anesthesia with conscious sedation seems to be a safe and effective alternative to the use of general anesthesia.

Haptic, Virtual Interaction and Motor Imagery: Entertainment Tools and Psychophysiological Testing.

In this work, the perception of affordances was analysed in terms of cognitive neuroscience during an interactive experience in a virtual reality environment. In particular, we chose a virtual reality scenario based on the Leap Motion controller: this sensor device captures the movements of the user's hand and fingers, which are reproduced on a computer screen by the proper software applications. For our experiment, we employed a sample of 10 subjects matched by age and sex and chosen among university students. The subjects took part in motor imagery training and immersive affordance condition (a virtual training with Leap Motion and a haptic training with real objects). After each training sessions the subject performed a recognition task, in order to investigate event-related potential (ERP) components. The results revealed significant differences in the attentional components during the Leap Motion training. During Leap Motion session, latencies increased in the occipital lobes, which are entrusted to visual sensory; in contrast, latencies decreased in the frontal lobe, where the brain is mainly activated for attention and action planning.

Estimation of the collective ionizing dose in the Portuguese population for the years 2011 and 2012, due to nuclear medicine exams / Estimación de la dosis colectiva en la población portuguesa de los años 2011 y 2012, debido a los exámenes de medicina nuclear

Objectives. In 2009-2010 a Portuguese consortium was created to implement the methodologies proposed by the Dose Datamed II (DDM2) project, aiming to collect data from diagnostic X-ray and nuclear medicine (NM) procedures, in order to determine the most frequently prescribed exams and the associated ionizing radiation doses for the Portuguese population. The current study is the continuation of this work, although it focuses only on NM exams for the years 2011 and 2012. Material and methods. The annual frequency of each of the 28 selected NM exams and the average administered activity per procedure was obtained by means of a nationwide survey sent to the 35 NM centres in Portugal. Results. The results show a reduction of the number of cardiac exams performed in the last two years compared with 2010, leading to a reduction of the annual average effective dose of Portuguese population due to NM exams from 0.08 mSv ± 0.017 mSv/caput to 0.059 ± 0.011 mSv/caput in 2011 and 0.054 ± 0.011 mSv/caput in 2012. Portuguese total annual average collective effective dose due to medical procedures was estimated to be 625.6 ± 110.9 manSv in 2011 and 565.1 ± 117.3 manSv in 2012, a reduction in comparison with 2010 (840.3 ± 183.8 manSv). Conclusions. The most frequent exams and the ones that contributed the most for total population dose were the cardiac and bone exams, although a decrease observed in 2011 and in 2012 was verified. The authors intend to perform this study periodically to identify trends in the annual Portuguese average effective dose and to help to raise awareness about the potential dose optimization (AU)

Objetivo. En 2009 y 2010 un consorcio portugués ha sido creado para implementar las metodologías propuestas por el proyecto europeo Datamed II (DDM2), con el objetivo de coleccionar datos de procedimientos de radiología de diagnóstico y medicina nuclear (MN) más frecuentes, así como la dosis asociada en la población portuguesa. Este estudio es una continuación del trabajo, que se centrará en los datos de MN para los años de 2011 y 2012. Material y Métodos. La frecuencia anual de cada uno de los 28 exámenes de MN seleccionados y la actividad media administrada por procedimiento se obtuvieron a través de una encuesta enviada a los 35 departamentos de MN en Portugal. Resultados. Los resultados muestran una reducción drástica en el número de procedimientos cardiacos en los últimos dos años, lo que tiene como consecuencia una reducción de la dosis efectiva anual en la población portuguesa derivado de procedimientos de MN de 0,08mSv±0,017 mSv/caput en 2010, a 0,059±0,011 mSv/caput in 2011 y 0,054±0,011 mSv/caput in 2012. La dosis efectiva colectiva media en la población portuguesa es estimada en 625.6 ± 110.9 manSv en 2011, y 565.1 ± 117.3 manSv en 2012. Conclusiones. Los exámenes cardiacos y óseos fueron más frecuentes y los que más contribuyeron para la dosis total de la población, aunque se verificó una disminución en 2011 y en 2012. Los autores de este trabajo pretenden realizar este tipo de estudios periódicamente para identificar tendencias en los diferentes procedimientos de MN y ayudar a aumentar la conciencia de los profesionales de MN sobre este asunto (AU)

Estimation of the collective ionizing dose in the Portuguese population for the years 2011 and 2012, due to nuclear medicine exams.

OBJECTIVES: In 2009-2010 a Portuguese consortium was created to implement the methodologies proposed by the Dose Datamed II (DDM2) project, aiming to collect data from diagnostic X-ray and nuclear medicine (NM) procedures, in order to determine the most frequently prescribed exams and the associated ionizing radiation doses for the Portuguese population. The current study is the continuation of this work, although it focuses only on NM exams for the years 2011 and 2012. MATERIAL AND METHODS: The annual frequency of each of the 28 selected NM exams and the average administered activity per procedure was obtained by means of a nationwide survey sent to the 35 NM centres in Portugal. RESULTS: The results show a reduction of the number of cardiac exams performed in the last two years compared with 2010, leading to a reduction of the annual average effective dose of Portuguese population due to NM exams from 0.08 mSv ± 0.017 mSv/caput to 0.059 ± 0.011 mSv/caput in 2011 and 0.054 ± 0.011 mSv/caput in 2012. Portuguese total annual average collective effective dose due to medical procedures was estimated to be 625.6 ± 110.9 manSv in 2011 and 565.1 ± 117.3 manSv in 2012, a reduction in comparison with 2010 (840.3 ± 183.8 manSv). CONCLUSIONS: The most frequent exams and the ones that contributed the most for total population dose were the cardiac and bone exams, although a decrease observed in 2011 and in 2012 was verified. The authors intend to perform this study periodically to identify trends in the annual Portuguese average effective dose and to help to raise awareness about the potential dose optimization.

Sobrevivência a médio prazo e estado funcional de pacientes com estenose valvar aórtica grave submetidos a implante transcateter da válvula aórtica / Medium-term survival and functional status of patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation

INTRODUÇÃO: O procedimento de implante transcateter da válvula aórtica (TAVI, do inglês transcatheter aortic valve implantation) representa opção de tratamento em pacientes com estenose valvar aórtica (EA) com risco cirúrgico elevado ou proibitivo. Relatamos nossa experiência usando o sistema autoexpansível Medtronic CoreValve®. MÉTODOS: No período de 2009 a 2013, 51 pacientes consecutivos com EA grave sintomática e risco cirúrgico alto ou proibitivo foram submetidos ao TAVI. Os resultados foram analisados de acordo com os critérios Valve Academic Research Consortium (VARC) -2. RESULTADOS: A média de idades dos pacientes foi 82 ± 6 anos, 49% eram do sexo feminino, 19% diabéticos, 21% tinham insuficiência renal e o EuroSCORE logístico foi 17,4 ± 11,4%. O sucesso do dispositivo foi alcançado em 84,3%. Todos os pacientes tiveram diminuição significativa dos gradientes transaórticos, que foi mantida ao longo do tempo. A internação hospitalar foi de 6 dias (intervalo interquartil: 5-8,8). A mortalidade intra-hospitalar e aos 30 dias foi 7,8% e 9,8%, respectivamente. Implante de marca-passo permanente foi necessário em 32,6% dos casos; acidente cerebrovascular isquêmico ocorreu em 3,9%; e complicações vasculares maiores em 6% dos pacientes. A sobrevivência aos 6 meses e em 1 ano foi 86,3% e 84,4%, respectivamente. A classe funcional NYHA melhorou significativamente após o TAVI e permaneceu baixa no seguimento de médio prazo. CONCLUSÕES: Nesta experiência preliminar, o tratamento de pacientes com EA e risco cirúrgico alto ou proibitivo com TAVI, usando o sistema autoexpansível CoreValve®, foi considerado viável e seguro, e levou à melhoria sustentável dos sintomas cardíacos. Após a superação dos riscos iniciais de morte e de acidente cerebrovascular, o procedimento garantiu um bom resultado clínico, no longo prazo.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with aortic valve stenosis (AS) and high or prohibitive surgical risk. We report our experience using the Medtronic CoreValveTM self-expending system. METHODS: From 2009 to 2013, 51 consecutive patients with severe symptomatic AS and high or prohibitive surgical risk were submitted to TAVI. Results were analyzed according to the criteria of the Valve Academic Research Consortium (VARC) -2. RESULTS: Mean age was 82 ± 6 years, 49% were female, 19% were diabetic, 21% had renal failure and the logistic EuroScore was 17.4 ± 11.4%. The success rate of the device was 84.3%. All of the patients had a significant decrease of transaortic gradients, which was maintained over time. Hospitalization time was 6 days (interquartile range: 5-8,8). In-hospital mortality at 30 days was 7.8% and 9.8%, respectively. Permanent pacemaker implantation was required in 32.6% of the cases, ischemic stroke was observed in 3.9% and major vascular complications in 6% of the patients. Survival at 6 months and 1 year was 86.3% and 84.4%, respectively. NYHA functional class improved significantly after TAVI and remained low in the medium-term follow-up. CONCLUSIONS: In this preliminary experience, the treatment of patients with AS and high or prohibitive surgical risk with TAVI, using the CoreValveTM self-expanding system was feasible and safe and led to sustained improvement of cardiac symptoms. After overcoming the initial risks of death and stroke, the procedure guaranteed good long-term clinical outcomes.

StentBoost Visualization for the Evaluation of Coronary Stent Expansion During Percutaneous Coronary Interventions.

INTRODUCTION: Inadequate stent implantation is associated with stent thrombosis and restenosis. StentBoost can enhance stent visualization and evaluate stent expansion. Currently, there are limited comparison studies between StentBoost and intravascular ultrasound (IVUS). We aimed to test the correlation and agreement between IVUS and StentBoost measurements. METHODS: From December 2010 to December 2011, 38 patients (54 stents) were analyzed using IVUS and StentBoost. Minimal stent diameter and proximal and distal edge stent diameter were compared between imaging techniques using Pearson correlation and Bland-Altman scatter plot. RESULTS: There was good correlation between StentBoost and IVUS measurements regarding minimal stent diameter (p < 0.001 in all stent portions) and an optimal agreement between IVUS and StentBoost, while lesser agreement was found between IVUS and quantitative coronary angiography. CONCLUSION: The assessment of stent implantation using StentBoost showed an adequate correlation and agreement with IVUS. This easily applicable angiographic technique can be used to guide stent implantation.

Tratamiento antiagregante guiado por pruebas de función plaquetaria en pacientes sometidos a angioplastia coronaria exitosa / Antiplatelet Therapy Guided by Platelet Function Testing after Successful Percutaneous Coronary Intervention / Antiplatelet Therapy Guided by Platelet Function testing after Successful Percutaneous Coronary Intervention Background

Introducción El tratamiento antiagregante dual con aspirina y clopidogrel constituye un tratamiento esencial para la prevención de eventos isquémicos en pacientes sometidos a angioplastia transluminal coronaria (ATC). Sin embargo, existe alta variabilidad interpaciente en la respuesta al clopidogrel, condicionando la falla en su efecto terapéutico, que se manifiesta como hiperreactividad plaquetaria residual (HPR). El prasugrel podría reducir este estado protrombótico. Objetivos 1) Estudiar la respuesta antiagregante en pacientes sometidos a ATC exitosa pretratados con clopidogrel o prasugrel y 2) evaluar la respuesta a una carga de prasugrel en pacientes con HPR bajo tratamiento con clopidogrel. Material y métodos Se incluyeron en forma prospectiva y consecutiva 83 pacientes sin riesgo hemorrágico alto sometidos a ATC exitosa bajo tratamiento antiagregante dual: aspirina más clopidogrel (600 mg de carga o mantenimiento de 75 mg/día por más de 7 días; n = 42) o prasugrel (60 mg de carga o mantenimiento de 10 mg/día por más de 7 días, n = 41). La selección de la tienopiridina quedó a cargo del médico tratante. La función plaquetaria se evaluó a las 12-24 horas pos-ATC con el método VerifyNow®. Se definió HPR a la presencia de ≥ 230 unidades de reactividad plaquetaria (URP). Los pacientes con HPR recibieron una dosis de carga de prasugrel de 60 mg y se repitió la evaluación de la función plaquetaria a las 2 horas. Resultados No hubo diferencias significativas en las características basales de ambos grupos. A las 12-24 horas pos-ATC, los pacientes tratados con prasugrel presentaron menos URP en comparación con el grupo clopidogrel [mediana 49 (9-78) vs. 160 (82-224); p < 0,001]. Se observó HPR en el 24% de los pacientes del grupo clopidogrel y cero en el grupo prasugrel (p < 0,001). Todos los pacientes con HPR bajo tratamiento con clopidogrel lograron corregirla luego de la carga de prasugrel. Conclusiones En pacientes sometidos a ATC exitosa, el tratamiento con prasugrel logró una mayor inhibición de la agregación plaquetaria (IAP) en comparación con la administración de clopidogrel. Por su parte, los pacientes con HPR bajo tratamiento con clopidogrel lograron alcanzar una IAP óptima con la administración adicional de prasugrel.

Dual antiplatelet therapy with aspirin and clopidogrel is an essential treatment to prevent ischemic events in patients undergoing percutaneous coronary intervention (PCI). However, a significant interindividual variability exists in response to clopidogrel treatment, which is responsible for failure in the therapeutic effect and in the development of high residual platelet reactivity (HRPR). Prasugrel could reduce this prothrombotic state. Objectives To evaluate: 1) the antiaggregant response in clopidogrel or prasugrel pretreated patients undergoing successful PCI, and 2) the response to prasugrel loading in patients with low residual platelet reactivity on clopidogrel therapy. Material and Methods Eighty three patients were prospectively included in the study. They underwent successful PCI under dual antiplatelet therapy: aspirin plus clopidogrel (600 mg loading dose or a maintenance dose of 75 mg for more than 7 days; n=42) or prasugrel (60 mg loading dose or a maintenance dose of 10 mg for more than 7 days; n=41). The selection of thienopyridine was left at the discretion of the treating physician. Patients with high hemorrhagic risk were excluded. Platelet function was tested 12-24 hours after PCI with the VerifyNowTM P2Y12 Assay. High residual platelet reactivity (HRPR) was defined as P2Y12-reaction units (PRU) ≥ 230. In case of HRPR, patients received a loading dose of prasugrel 60 mg and platelet function was reassessed 2 hours later. Results Baseline characteristics did not differ in patients who initially received clopidogrel or prasugrel. At 12-24 hours post PCI, patients treated with prasugrel presented significantly less PRU compared with the clopidogrel cohort (median 49 (9-78) vs. 160 (82-224); p < 0.001). HRPR was observed in 24% of patients in the clopidogrel group and in no patients in the prasugrel cohort (p < 0.001). All patients with HRPR on clopidogrel treatment corrected this value after the loading dose of prasugrel. Conclusions After successful PCI, prasugrel administration achieved greater platelet inhibition compared to clopidogrel. Moreover, in patients with high-on treatment platelet reactivity with clopidogrel, optimal platelet inhibition was accomplished by additional prasugrel administration.

Tratamiento antiagregante guiado por pruebas de función plaquetaria en pacientes sometidos a angioplastia coronaria exitosa / Antiplatelet Therapy Guided by Platelet Function Testing after Successful Percutaneous Coronary Intervention / Antiplatelet Therapy Guided by Platelet Function testing after Successful Percutaneous Coronary Intervention Background

Introducción El tratamiento antiagregante dual con aspirina y clopidogrel constituye un tratamiento esencial para la prevención de eventos isquémicos en pacientes sometidos a angioplastia transluminal coronaria (ATC). Sin embargo, existe alta variabilidad interpaciente en la respuesta al clopidogrel, condicionando la falla en su efecto terapéutico, que se manifiesta como hiperreactividad plaquetaria residual (HPR). El prasugrel podría reducir este estado protrombótico. Objetivos 1) Estudiar la respuesta antiagregante en pacientes sometidos a ATC exitosa pretratados con clopidogrel o prasugrel y 2) evaluar la respuesta a una carga de prasugrel en pacientes con HPR bajo tratamiento con clopidogrel. Material y métodos Se incluyeron en forma prospectiva y consecutiva 83 pacientes sin riesgo hemorrágico alto sometidos a ATC exitosa bajo tratamiento antiagregante dual: aspirina más clopidogrel (600 mg de carga o mantenimiento de 75 mg/día por más de 7 días; n = 42) o prasugrel (60 mg de carga o mantenimiento de 10 mg/día por más de 7 días, n = 41). La selección de la tienopiridina quedó a cargo del médico tratante. La función plaquetaria se evaluó a las 12-24 horas pos-ATC con el método VerifyNow«. Se definió HPR a la presencia de ≥ 230 unidades de reactividad plaquetaria (URP). Los pacientes con HPR recibieron una dosis de carga de prasugrel de 60 mg y se repitió la evaluación de la función plaquetaria a las 2 horas. Resultados No hubo diferencias significativas en las características basales de ambos grupos. A las 12-24 horas pos-ATC, los pacientes tratados con prasugrel presentaron menos URP en comparación con el grupo clopidogrel [mediana 49 (9-78) vs. 160 (82-224); p < 0,001]. Se observó HPR en el 24% de los pacientes del grupo clopidogrel y cero en el grupo prasugrel (p < 0,001). Todos los pacientes con HPR bajo tratamiento con clopidogrel lograron corregirla luego de la carga de prasugrel. Conclusiones En pacientes sometidos a ATC exitosa, el tratamiento con prasugrel logró una mayor inhibición de la agregación plaquetaria (IAP) en comparación con la administración de clopidogrel. Por su parte, los pacientes con HPR bajo tratamiento con clopidogrel lograron alcanzar una IAP óptima con la administración adicional de prasugrel.(AU)

Dual antiplatelet therapy with aspirin and clopidogrel is an essential treatment to prevent ischemic events in patients undergoing percutaneous coronary intervention (PCI). However, a significant interindividual variability exists in response to clopidogrel treatment, which is responsible for failure in the therapeutic effect and in the development of high residual platelet reactivity (HRPR). Prasugrel could reduce this prothrombotic state. Objectives To evaluate: 1) the antiaggregant response in clopidogrel or prasugrel pretreated patients undergoing successful PCI, and 2) the response to prasugrel loading in patients with low residual platelet reactivity on clopidogrel therapy. Material and Methods Eighty three patients were prospectively included in the study. They underwent successful PCI under dual antiplatelet therapy: aspirin plus clopidogrel (600 mg loading dose or a maintenance dose of 75 mg for more than 7 days; n=42) or prasugrel (60 mg loading dose or a maintenance dose of 10 mg for more than 7 days; n=41). The selection of thienopyridine was left at the discretion of the treating physician. Patients with high hemorrhagic risk were excluded. Platelet function was tested 12-24 hours after PCI with the VerifyNowTM P2Y12 Assay. High residual platelet reactivity (HRPR) was defined as P2Y12-reaction units (PRU) ≥ 230. In case of HRPR, patients received a loading dose of prasugrel 60 mg and platelet function was reassessed 2 hours later. Results Baseline characteristics did not differ in patients who initially received clopidogrel or prasugrel. At 12-24 hours post PCI, patients treated with prasugrel presented significantly less PRU compared with the clopidogrel cohort (median 49 (9-78) vs. 160 (82-224); p < 0.001). HRPR was observed in 24% of patients in the clopidogrel group and in no patients in the prasugrel cohort (p < 0.001). All patients with HRPR on clopidogrel treatment corrected this value after the loading dose of prasugrel. Conclusions After successful PCI, prasugrel administration achieved greater platelet inhibition compared to clopidogrel. Moreover, in patients with high-on treatment platelet reactivity with clopidogrel, optimal platelet inhibition was accomplished by additional prasugrel administration.(AU)

From planning to practice: building the national network for the Surveillance of Severe Maternal Morbidity.

BACKGROUND: Improving maternal health is one of the Millennium Development Goals for 2015. Recently some progress has been achieved in reducing mortality. On the other hand, in developed regions, maternal death is a relatively rare event compared to the number of cases of morbidity; hence studying maternal morbidity has become more relevant. Electronic surveillance systems may improve research by facilitating complete data reporting and reducing the time required for data collection and analysis. Therefore the purpose of this study was to describe the methods used in elaborating and implementing the National Network for the Surveillance of Severe Maternal Morbidity in Brazil. METHODS: The project consisted of a multicenter, cross-sectional study for the surveillance of severe maternal morbidity including near-miss, in Brazil. RESULTS: Following the development of a conceptual framework, centers were selected for inclusion in the network, consensus meetings were held among the centers, an electronic data collection system was identified, specific software and hardware tools were developed, research material was prepared, and the implementation process was initiated and analyzed. CONCLUSION: The conceptual framework developed for this network was based on the experience acquired in various studies carried out in the area over recent years and encompasses maternal and perinatal health. It is innovative especially in the context of a developing country. The implementation of the project represents the first step towards this planned management. The system online elaborated for this surveillance network may be used in further studies in reproductive and perinatal health.

Quality of myocardial reperfusion according to ischemic time and infarcted territory.

BACKGROUND: The relationship of the ischemic time to primary angioplasty and the quality of myocardial reperfusion according to infarcted territory among patients with ST-segment elevation myocardial infarction (STEMI) is unclear. METHODS: This study consisted of 140 patients with STEMI within 12 h from the symptom onset and undergoing a primary angioplasty from the Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction Trial. ST-segment resolution (STR) at 60 min was analyzed by an independent corelab using continuous ST monitoring. Patients were divided according to anterior (n=74) and nonanterior (n=64) locations and according to ischemic time in quartiles (<90, 90-148, 148-241, and 241-635 min). RESULTS: Although there was no significant decrement in the extent of STR with the ischemic time in the entire population (74, 51, 72, and 51%, respectively, P=not significant), patients with anterior location have a significant reduction in the extent of STR after 90 min compared with those coming after 90 min (70.6 vs. 29.2% of complete STR, P=0.003, respectively). CONCLUSION: Patients with anterior STEMI seem to have a stronger impact of ischemic time on the quality of myocardial reperfusion compared with patients with nonanterior location.

Evaluación de las revascularizaciones coronarias denominadas inapropiadas por la nueva clasificación de adecuación de procedimientos en un centro cardiovascular de alta complejidad / Evaluation of Inappropriate Coronary Revascularization Procedures According to the New Classification in a Cardiovascular Tertiary Referral Center

Introducción Una revascularización coronaria inapropiada conlleva un riesgo muchas veces evitable para el paciente y se traduce en gastos innecesarios para el sistema de salud. Recientemente, los miembros de un panel de expertos en enfermedades cardiovasculares evaluaron el criterio de adecuación de la indicación de revascularización coronaria en varios escenarios clínicos comunes. Objetivos Identificar la proporción de revascularización coronaria inapropiada tanto percutánea (ATC) como quirúrgica (CRM) conforme al criterio de adecuación en un centro de alta complejidad cardiovascular. Material y métodos Desde enero hasta mayo de 2009 se incluyeron en forma consecutiva todos los pacientes derivados a nuestro centro con la indicación clínica de coronariografía que presentaron enfermedad coronaria significativa (estenosis ≥ 70%) y fueron sometidos a revascularización percutánea o quirúrgica. Se evaluó en este grupo la tasa de indicación inapropiada de revascularización coronaria conforme el criterio de adecuación recientemente publicado. Resultados De 568 cateterismos evaluados, 404 (71,2%) presentaron al menos una lesión ≥ 70% de estenosis, 81 pacientes fueron sometidos a CRM (20%) y 295 a ATC (73%). Del total de 376 pacientes revascularizados, la indicación de revascularización coronaria se consideró inapropiada en 15 (4%), todos ellos del grupo ATC (15/295; 5%), mientras que en el grupo de pacientes multiarteriales (n = 172) sólo 2 (1,2%) revascularizaciones resultaron inapropiadas. Conclusiones El criterio de adecuación de revascularización coronaria (percutánea o quirúrgica) en un centro cardiovascular de alta complejidad ha resultado inapropiado en una minoría de los casos. Dicho criterio representa una herramienta potencialmente aplicable tanto en la toma de decisiones en pacientes con enfermedad coronaria como en el control de calidad de los servicios de cardiología.

Background Inappropriate use of revascularization may be potentially harmful to patients and generate unwarranted costs to the health care system. Recently, the members of an expert panel conducted an appropriateness review of common clinical scenarios in which coronary revascularization is frequently considered. Objectives To identify the proportion of inappropriate coronary revascularization procedures -percutaneous (PTCA) and surgical (CABG) - in a cardiovascular tertiary referral center according to appropriateness criterion. Material and Methods We consecutively included all patients referred to our center for coronary angiography from January to May 2009 with a significant coronary stenosis (≥ 70%) who underwent percutaneous or surgical revascularization, and evaluated the rate of inappropriate revascularization according to appropriateness criterion recently published. Results From a total of 568 coronary angiographies, 404 (71.2%) had at least a coronary stenosis ≥70%; 81 patients underwent CABGS (20%) and 295 PTCA (73%). In these 376 revascularized patients, the indication was considered inappropriate in 15 (4%), all of them in the PTCA group (15/295; 5%), while only 2 patients with multivessel disease (n=172, 1.2%) underwent inappropriate revascularization. Conclusions In a cardiovascular tertiary referral center, the proportion of inappropriate coronary revascularization procedures (percutaneous or surgical) was low. Appropriateness criterion may be an applicable tool for decision-making in patients with coronary artery disease and for quality control in the departments of cardiology.

Time to stable ST-segment recovery following primary angioplasty is predictive of regional wall motion score and clinical outcome.

We report the time to stable ST-segment reperfusion (TSTR) after primary angioplasty and its relationship with the clinical results; 137 patients who underwent primary angioplasty were included as part of the analysis. All patients had 24 hours ST-segment monitoring. Time to stable STR was defined as the beginning of ST-segment reperfusion (STR) lasting >4 hours without ST-segment reelevation. Six-month mortality was associated with slower TSTR (median 166.5 vs 6 minute, P = .001). Time to stable STR cutoff value of 136.5 minutes was identified as the best mortality predictor (area under the curve: 0.86, P = .001). Multivariate analysis identified Killip class > or = 2 (P = .042), TSTR cutoff value (P = .002), and final thrombolysis myocardial infarction (TIMI) flow grade III (P = .067) as predictors of 6-month mortality. Time to stable STR may be a novel continuous electrocardiogram (ECG) parameter following primary angioplasty, which can identify high-risk patients that need to be considered for additional treatments.

Virtual model of the human brain for neurosurgical simulation.

The aim of this work is to develop a realistic virtual model of the human brain that could be used in a neurosurgical simulation for both educational and preoperative planning purposes. The goal of such a system would be to enhance the practice of surgery students, avoiding the use of animals, cadavers and plastic phantoms. A surgeon, before carrying out the real procedure, will, with this system, be able to rehearse by using a surgical simulator based on detailed virtual reality models of the human brain, reconstructed with real patient's medical images. In order to obtain a realistic and useful simulation we focused our research on the physical modelling of the brain as a deformable body and on the interactions with surgical instruments. The developed prototype is based on the mass-spring-damper model and, in order to obtain deformations similar to the real ones, a three tiered structure has been built. In this way, we have obtained local and realistic deformations using an ad-hoc point distribution in the volume where the contact between the brain surface and a surgical instrument takes place.

A virtual interface for interactions with 3D models of the human body.

The developed system is the first prototype of a virtual interface designed to avoid contact with the computer so that the surgeon is able to visualize 3D models of the patient's organs more effectively during surgical procedure or to use this in the pre-operative planning. The doctor will be able to rotate, to translate and to zoom in on 3D models of the patient's organs simply by moving his finger in free space; in addition, it is possible to choose to visualize all of the organs or only some of them. All of the interactions with the models happen in real-time using the virtual interface which appears as a touch-screen suspended in free space in a position chosen by the user when the application is started up. Finger movements are detected by means of an optical tracking system and are used to simulate touch with the interface and to interact by pressing the buttons present on the virtual screen.