Indicación de desfibrilador automático implantable en paciente con angina de Prinzmetal y síncopes / No disponible

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[Bloodless cardiac surgery in Jehovah's witnesses: outcomes compared with a control group]. / Cirugía cardiaca sin sangre en testigos de Jehová: resultados frente a grupo control.

INTRODUCTION AND OBJECTIVES: Some patients, such as Jehovah's Witnesses, refuse to use blood products, which can make it difficult to achieve the same outcomes as in the general population. The objective of this study was to determine whether clinical characteristics and surgical outcomes in Jehovah's Witnesses undergoing cardiac surgery are similar to those in other patients. METHODS: Paired-group retrospective cohort study. All Jehovah's Witnesses undergoing cardiac surgery between January 1998 and September 2006 were included (n=59). Cases were matched on a 1:1 basis according to sex, age (5) years, year and type of surgery, and need for repeat surgery. Preoperative, intraoperative and postoperative data were analyzed. RESULTS: The mean age of cases was 62.5 (11.1) years with 57.6% being female. Some 30.5% had had at least one previous cardiac intervention. The clinical characteristics of the two groups were similar. Hemoglobin and hematocrit levels were higher in Jehovah's Witnesses both before (13.6 g/dL vs 12.9 g/dL; P=.01, and 40.7% vs 39%; P=.09) and after (11 g/dL vs 10 g/dL; P=.003, and 34.2% vs 30.7%; P=.001) surgery. Jehovah's Witnesses experienced significantly less bleeding, were intubated for fewer hours, and had shorter stays in both intensive care and the hospital. There was no difference in the rate of postoperative complications or mortality. CONCLUSIONS: The clinical characteristics of Jehovah's Witnesses were similar to those of the control group. The complication rate was also similar in these patients, though the number of hours of mechanical ventilation was less, 24-hour bleeding was less, and the hospital stay was shorter. Mortality was similar in the two groups.

Cirugía cardiaca sin sangre en testigos de Jehová: resultados frente a grupo control / Bloodless cardiac surgery in Jehovah's witnesses: outcomes compared with a control group

Introducción y objetivos. Algunos pacientes, como los testigos de Jehová (TJ), rechazan el uso de hemoderivados, lo cual podría ser un inconveniente para ofrecerles los mismos resultados que a la población general. El objetivo es comprobar si las características de los TJ intervenidos de cirugía cardiaca y su morbimortalidad son similares a las del resto de pacientes. Métodos. Estudio retrospectivo de cohortes con grupos emparejados. Entre enero de 1998 y septiembre de 2006 se seleccionaron todos los TJ intervenidos de cirugía cardiaca (n = 59). Se empleó una técnica de emparejamiento 1:1 a partir de las siguientes variables: sexo, edad ± 5 años, año y tipo de cirugía y reintervención o no. Se analizaron las variables preoperatorias, intraoperatorias y postoperatorias. Resultados. La edad media de los casos fue de 62,5 ± 11,1 años, con un 57,6% de mujeres. El 30,5% de los pacientes presentaba una reintervención. Las características clínicas de ambos grupos fueron similares. Las concentraciones de hemoglobina y hematocrito preoperatorias (13,6 frente a 12,9 g/dl; p = 0,01; 40,7 frente a 39%; p = 0,09) y postoperatorias (11 frente a 10 g/dl; p = 0,003; 34,2 frente a 30,7%; p = 0,001) fueron mejores en los TJ. Éstos presentaron significativamente un menor sangrado, un menor número de horas de intubación y una menor estancia en la unidad de vigilancia intensiva y hospitalaria. No hubo diferencias en cuanto a la incidencia de complicaciones y mortalidad. Conclusiones. Las características de los pacientes TJ fueron comparables con las del grupo control. La incidencia de complicaciones en estos pacientes fue similar, con un menor número de horas de intubación, un menor sangrado a las 24 horas y una menor estancia hospitalaria. La mortalidad en ambos grupos fue similar (AU)

Introduction and objectives. Some patients, such as Jehovah's Witnesses, refuse to use blood products, which can make it difficult to achieve the same outcomes as in the general population. The objective of this study was to determine whether clinical characteristics and surgical outcomes in Jehovah's Witnesses undergoing cardiac surgery are similar to those in other patients. Methods. Paired-group retrospective cohort study. All Jehovah's Witnesses undergoing cardiac surgery between January 1998 and September 2006 were included (n=59). Cases were matched on a 1:1 basis according to sex, age (5) years, year and type of surgery, and need for repeat surgery. Preoperative, intraoperative and postoperative data were analyzed. Results. The mean age of cases was 62.5 (11.1) years with 57.6% being female. Some 30.5% had had at least one previous cardiac intervention. The clinical characteristics of the two groups were similar. Hemoglobin and hematocrit levels were higher in Jehovah's Witnesses both before (13.6 g/dL vs 12.9 g/dL; P=.01, and 40.7% vs 39%; P=.09) and after (11 g/dL vs 10 g/dL; P=.003, and 34.2% vs 30.7%; P=.001) surgery. Jehovah's Witnesses experienced significantly less bleeding, were intubated for fewer hours, and had shorter stays in both intensive care and the hospital. There was no difference in the rate of postoperative complications or mortality. Conclusions. The clinical characteristics of Jehovah's Witnesses were similar to those of the control group. The complication rate was also similar in these patients, though the number of hours of mechanical ventilation was less, 24-hour bleeding was less, and the hospital stay was shorter. Mortality was similar in the two groups (AU)

[Direct stent implantation in acute myocardial infarction. The DISCO 3 study]. / Implante directo del stent en el infarto agudo de miocardio. Estudio DISCO 3.

INTRODUCTION AND OBJECTIVES: An association has been reported between direct stenting in primary angioplasty and low incidences of the no-reflow phenomenon and distal embolization. The aims of this study were to determine the proportion of patients who can be treated by direct stent implantation and to identify factors that establish when the technique should be used in acute myocardial infarction in clinical practice. PATIENTS AND METHOD: This prospective descriptive and multicenter study (DISCO 3) included 189 patients. Angiographic reperfusion parameters were recorded and resolution of the ST-segment elevation was monitored. Adverse clinical events, such as death, non-fatal reinfarction and repeat revascularization of the culprit vessel, were recorded at discharge, and after one and six months. RESULTS: Direct stenting was performed in 56% of patients, and stenting after predilatation in 44%. The main predictors of direct stenting were short postinfarction delay, non-zero initial TIMI flow, and preinfarction angina. The most common reasons for balloon predilatation were TIMI flow zero on traversing the lesion with a guidewire (92%), involvement of a major bifurcation or tortuous vessel, and severe calcification. Indices of myocardial reperfusion were better with direct stenting: TIMI myocardial perfusion grade 2-3 flow was present in 84% vs 69% (P=.005), and > 70% ST-segment resolution occurred in 66% vs 42% (P=.003). No difference in adverse clinical events was found. CONCLUSIONS: Direct stenting is feasible for treating acute myocardial infarction in more than half of patients. The lesions should not be severely calcified nor involve tortuous vessels, and there should be sufficient flow following passage of a guidewire to define the lesion's characteristics.

Implante directo del stent en el infarto agudo de miocardio. Estudio DISCO 3 / Direct stent implantation in acute myocardial infarction. The DISCO 3 study

Introducción y objetivos. El implante directo del stent en la angioplastia primaria se ha asociado con una menor incidencia de no reflujo y embolización distal. El objetivo de este estudio fue evaluar la proporción de pacientes que puede ser tratada y los factores que determinan la implantación directa del stent en el infarto agudo de miocardio en la práctica habitual. Pacientes y método. Se incluyó a 189 pacientes en este estudio descriptivo, prospectivo y multicéntrico (DISCO 3). Se analizaron los resultados angiográficos y de resolución de la elevación del segmento ST. Se registraron los acontecimientos clínicos (muerte, reinfarto no mortal y nueva revascularización del vaso causante) en el momento del alta, al mes y a los 6 meses. Resultados. Se trató con stent directo (SD) al 56% de los pacientes y con stent tras predilatación (SP) al 44%. Los mejores predictores de SD fueron: menor tiempo de evolución del infarto, flujo TIMI inicial distinto de 0 y presencia de angina preinfarto. Los motivos para la predilatación fueron: presencia de un flujo TIMI 0 tras cruzar la lesión (92%), bifurcación mayor, calcificación y tortuosidad severas. Los índices de reperfusión miocárdica fueron mejores en el grupo de SD, con un grado de perfusión miocárdica TIMI 2-3 (el 84 frente al 69%; p = 0,005) y una resolución del segmento ST > 70% (el 66 frente al 42%; p = 0,003). No hubo diferencias significativas en la presencia de eventos clínicos adversos en el seguimiento. Conclusiones. El uso del SD en el tratamiento del infarto agudo de miocardio de menos de 12 h de evolución es factible en más de la mitad de los casos, cuando las lesiones no presentan calcificación y/o tortuosidad severas, y cuando se consigue, tras el paso de la guía, un flujo mínimo que permita definir las características de la lesión

Introduction and objectives. An association has been reported between direct stenting in primary angioplasty and low incidences of the no-reflow phenomenon and distal embolization. The aims of this study were to determine the proportion of patients who can be treated by direct stent implantation and to identify factors that establish when the technique should be used in acute myocardial infarction in clinical practice. Patients and method. This prospective descriptive and multicenter study (DISCO 3) included 189 patients. Angiographic reperfusion parameters were recorded and resolution of the ST-segment elevation was monitored. Adverse clinical events, such as death, non-fatal reinfarction and repeat revascularization of the culprit vessel, were recorded at discharge, and after one and six months. Results. Direct stenting was performed in 56% of patients, and stenting after predilatation in 44%. The main predictors of direct stenting were short postinfarction delay, non-zero initial TIMI flow, and preinfarction angina. The most common reasons for balloon predilatation were TIMI flow zero on traversing the lesion with a guidewire (92%), involvement of a major bifurcation or tortuous vessel, and severe calcification. Indices of myocardial reperfusion were better with direct stenting: TIMI myocardial perfusion grade 2-3 flow was present in 84% vs 69% (P=.005), and > 70% ST-segment resolution occurred in 66% vs 42% (P=.003). No difference in adverse clinical events was found. Conclusions. Direct stenting is feasible for treating acute myocardial infarction in more than half of patients. The lesions should not be severely calcified nor involve tortuous vessels, and there should be sufficient flow following passage of a guidewire to define the lesion's characteristics

Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial.

BACKGROUND: In patients with ST-segment elevated myocardial infarction (STEMI), early post-thrombolysis routine angioplasty has been discouraged because of its association with high incidence of events. The GRACIA-1 trial was designed to reassess the benefits of an early post-thrombolysis interventional approach in the era of stents and new antiplatelet agents. METHODS: 500 patients with thrombolysed STEMI (with recombinant tissue plasminogen activator) were randomly assigned to angiography and intervention if indicated within 24 h of thrombolysis, or to an ischaemia-guided conservative approach. The primary endpoint was the combined rate of death, reinfarction, or revascularisation at 12 months. Analysis was by intention to treat. FINDINGS: Invasive treatment included stenting of the culprit artery in 80% (199 of 248) patients, bypass surgery in six (2%), non-culprit artery stenting in three, and no intervention in 40 (16%). Predischarge revascularisation was needed in 51 of 252 patients in the conservative group. By comparison with patients receiving conservative treatment, by 1 year, patients in the invasive group had lower frequency of primary endpoint (23 [9%] vs 51 [21%], risk ratio 0.44 [95% CI 0.28-0.70], p=0.0008), and they tended to have reduced rate of death or reinfarction (7% vs 12%, 0.59 [0.33-1.05], p=0.07). Index time in hospital was shorter in the invasive group, with no differences in major bleeding or vascular complications. At 30 days both groups had a similar incidence of cardiac events. In-hospital incidence of revascularisation induced by spontaneous recurrence of ischaemia was higher in patients in the conservative group than in those in the invasive group. INTERPRETATION: In patients with STEMI, early post-thrombolysis catheterisation and appropriate intervention is safe and might be preferable to a conservative strategy since it reduces the need for unplanned in-hospital revascularisation, and improves 1-year clinical outcome.

[Nonselected use of direct coronary stenting. The DISCO 2 trial]. / Uso amplio de stenting coronaro directo. Estudio DISCO 2.

INTRODUCTION AND OBJECTIVES: Direct coronary stenting yields immediate long-term clinical results similar to those obtained with balloon predilation, with the advantage of lower costs and procedural times. Until now, direct stenting has been attempted only for selected lesions, so that the potential scope of its use in everyday practice remains unknown. The DISCO 2 trial was designed to identify the number and type of lesions that could be safely treated by direct stenting. Patients and method. 1,269 lesions (886 patients) were treated consecutively in 7 different hospitals. Direct stenting was attempted in all cases, except for total chronic occlusions, severe tortuosity or calcification of the vessel, lesions in the sinus ostium, or bifurcated lesions and vessel diameter < 2.4 mm. If the procedure failed, the stent was recovered and the lesion dilated with a balloon before a second attempt at stenting. RESULTS: Direct stenting was attempted in 585 lesions (54.9% of all electively implanted stents and 46.1% of all angioplasties). This was successful in 553 (94.6%) and failed in 32 (5.4%). In 30 of these latter patients a stent was implanted after predilation. Predictors of failure were tortuosity, location in the nonproximal right coronary artery, age > 65 years and type B2 or C lesion. After 6 months of follow-up the total incidence of major adverse cardiovascular events in patients treated with direct stenting was 6.2%, with a target lesion revascularization rate of 4.45%. CONCLUSIONS: In a mostly nonselected sample of coronary lesions, direct stenting was as safe as stenting with predilation. More than half of all elective stenting procedures can be attempted safely without balloon predilation. Greater need for predilation was associated with tortuosity, nonproximal right coronary artery location, older age and lesion complexity (B2, C). The 6-month clinical outcome was excellent, with a low rate of repeat revascularization.

Uso amplio de stenting coronario directo. Estudio DISCO 2 / Nonselected use of direct coronary stenting. The DISCO 2 trial

Introducción y objetivos. El stenting directo ofrece resultados inmediatos y a largo plazo similares a los del implante con predilatación, con la ventaja de una reducción en el coste y la duración del procedimiento. Hasta el momento, su uso se ha limitado a lesiones seleccionadas, por lo que el campo real de aplicación no se conoce. El estudio DISCO 2 pretende identificar el número y las características de las lesiones donde el stenting directo puede realizarse con seguridad en la práctica diaria. Pacientes y método. Se trataron 1.269 lesiones coronarias consecutivas, intentándose stenting directo en todas excepto en los casos de oclusión completa crónica, tortuosidad o calcificación severas, lesión aortostial o en bifurcación y diámetro del vaso inferior a 2,4 mm. Si el procedimiento fracasaba, se recuperaba el stent y se dilataba la lesión con balón antes de realizar un segundo intento con stent. Resultados. Se abordaron con stent directo 585 lesiones (el 54,9 por ciento de todos los stents implantados electivamente y el 46,1 por ciento de todos los procedimientos de angioplastia), con éxito en 553 (94,6 por ciento) y fracaso en 32 (5,4 por ciento), de los que en 30 se implantó stent tras realizar una predilatación. Se asociaron a la necesidad de predilatación la tortuosidad excesiva, la localización en la coronaria derecha no proximal, la edad superior a 65 años y el tipo de lesión B2 o C. A los 6 meses, la incidencia de acontecimientos cardiovasculares adversos mayores en los pacientes con stenting directo fue del 6,2 por ciento, con una tasa de revascularización repetida del 4,45 por ciento. Conclusiones. En lesiones coronarias poco seleccionadas, el stenting directo es tan seguro como el implante tras predilatación. Más de la mitad de las lesiones tratadas electivamente con un stent son adecuadas para stenting directo. La posibilidad de éxito se reduce con la tortuosidad excesiva, la localización en la coronaria derecha no proximal, la mayor edad y la lesión compleja (B2, C) (AU)

Stenting directo: ¿el ocaso del balón? / Direct stenting: The declane of balloon?

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