RESUMO
BACKGROUND: Anti-myosin antibodies (AMAs) are often formed in response to myocardial infarction (MI) and have been implicated in maladaptive cardiac remodelling. We aimed to: (1) compare AMA formation in patients with Non-ST-Elevation MI (NSTEMI) and ST-Elevation MI (STEMI); (2) evaluate factors predicting autoantibody formation; and, (3) explore their functional significance. METHODS: Immunoglobulin M (IgM) and Immunoglobulin G (IgG) AMA titres were determined in serum samples collected at admission, 3 and 6 months post MI. The relationship between demographic and clinical data, and antibody formation, was investigated to determine factors predicting antibody formation and functional significance. RESULTS: Forty-three (43) patients were consecutively recruited; 74.4% were positive for IgM at admission, compared with 23.3% for IgG. Mean IgG levels increased by 1.24% (±0.28) at 3 months, and 13.55% (±0.13) at 6 months post MI. Mean antibody levels were significantly higher in the NSTEMI cohort at both follow-up time points for IgG (p<0.001, p<0.0001), but not IgM (p=0.910, p=0.066). A moderately positive correlation between infarct size and increase in mean IgM concentration was observed at 3 months (r(98)=0.455; p=0.015). Anti-myosin antibody formation was not associated with an unfavourable outcome at follow-up. CONCLUSIONS: Anti-myosin antibodies are formed in a significant proportion of patients following MI, particularly among those with NSTEMI. While IgM levels fall after infarction, IgG levels increase and persist beyond 6 months of follow-up. This raises the possibility that they may contribute to long-term myocardial damage and dysfunction. Future research should focus on the specific epitopes that are targeted by these antibodies, and their functional significance. This may result in the emergence of novel therapies to attenuate cardiac dysfunction in MI patients.
Assuntos
Autoanticorpos/sangue , Autoimunidade , Infarto do Miocárdio/imunologia , Miosinas/imunologia , Biomarcadores/sangue , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de TempoRESUMO
Recent improvements in medical and surgical coronary revascularization techniques have significantly improved outcomes for patients with acute myocardial infarction (MI). However, large infarctions are often followed by a poorly understood process of pathological ventricular remodelling, which fails to return the heart to its premorbid state. Although it remains incompletely understood, there is increasing interest in the role of the immune system in this process. One hypothesis is that released cardiac proteins become the focus of an immune response that results in the formation of functionally significant autoantibodies. This review summarizes the current literature, both human and animal, relating to the formation and clinical relevance of anti-troponin antibodies (ATAs) in patients with MI.
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Autoanticorpos/sangue , Infarto do Miocárdio/imunologia , Troponina/imunologia , Remodelação Ventricular/imunologia , Animais , Feminino , Humanos , Masculino , Infarto do Miocárdio/sangueRESUMO
The transradial approach has become the gold-standard for coronary angiography. It is better tolerated by patients, associated with less bleeding, earlier post-procedure mobilization, and reduced mortality in patients with myocardial infarction. Given the hand's dual arterial supply and extensive collateral circulation, the risk of serious functional injury after radial catheterization is essentially reduced to zero. However, even a small amount of bleeding in the volar compartment can lead to compartment syndrome (CS) and permanent neurovascular injury. The purpose of this paper is to describe our experience with an unusual case of late-onset acute CS following transradial coronary angiography, and to summarize the available literature on this topic.
RESUMO
Recent improvements in the medical and surgical management of myocardial infarction mean that many patients are now surviving with greater impairment of cardiac function. Despite appropriate management, some of these patients subsequently develop pathological ventricular remodelling, which compounds their contractile dysfunction and can lead to congestive cardiac failure (CCF). The pathophysiological mechanism underpinning this process remains incompletely understood. One hypothesis suggests that a post-infarction autoimmune response, directed against constituents of cardiac myocytes, including cardiac myosin, may make an important contribution. Our review summarises the current literature related to the formation and clinical relevance of anti-myosin antibodies (AMAs) in patients with myocardial infarction. This discussion is supplemented with reference to a number of important animal studies, which provide evidence of the potential mechanisms underlying AMA formation and autoantibody mediated cardiac dysfunction.
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Autoanticorpos/sangue , Miosinas Cardíacas/sangue , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Animais , Autoimunidade/fisiologia , Humanos , Miocárdio/patologiaRESUMO
Saphenous vein graft aneurysms are an uncommon late complication of coronary artery bypass surgery (CABG). Management strategies include surgical revision, percutaneous closure using covered stent grafts, coil embolisation, vascular plug insertion and ethylene vinyl alcohol copolymer injection. We report a case of a very large saphenous vein graft aneurysm successfully treated with a covered stent graft.
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Aneurisma/cirurgia , Ponte de Artéria Coronária/efeitos adversos , Enxerto Vascular/efeitos adversos , Idoso , Aneurisma/diagnóstico por imagem , Aneurisma/etiologia , Humanos , Masculino , Radiografia , Veia Safena , StentsRESUMO
Serious paravalvular leakage occurs in 1-5% of patients who have undergone surgical cardiac valve replacement procedures. Clinical manifestations include hemolysis, heart failure and arrhythmias. Presently, the gold standard treatment for severe paravalvular leakage is surgery; however, the outcomes remain far from optimum. In this Review we discuss the problem of paravalvular leak and focus on the role of percutaneous repair as a treatment option.
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Oclusão com Balão/métodos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Próteses Valvulares Cardíacas/efeitos adversos , Complicações Pós-Operatórias/terapia , Cateterismo Cardíaco , Ecocardiografia Transesofagiana , Feminino , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Prognóstico , Falha de Prótese , Medição de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: This study evaluates the in-hospital, 30 day and long-term results of stenting for unprotected left main coronary artery disease in our institution. METHODS: Between April 2001 and October 2005 all unprotected left main cases were retrospectively reviewed. Outcomes were obtained by case note review and postal questionnaire; primary care physicians were contacted to complete missing data. RESULTS: We identified 100 consecutive patients who underwent unprotected left main procedures, 1.44% of the institution PCI volume. Indications for a percutaneous strategy were non-surgical candidates (47), emergency revascularisation (25) and patient/physician preference (28). Overall procedural success was 97%. The majority of cases (n=78) were performed with a single-stent strategy. 55% received a drug-eluting stent. There were 7 in-hospital deaths, 5 in the emergency group (cardiogenic shock) and 2 non-CABG candidates. Post hospital discharge long-term clinical follow-up was 651+/-431 days (range 6-1741). There were 8 deaths post discharge. Patients presenting as an emergency had a 72% survival rate at long-term follow-up, non-surgical candidates 83%, and patient/physician preference group had a 100% long-term survival. Multivariate analysis revealed cardiogenic shock (HR=7.9, 95% CI 1.7-3.6, p=0.008), failed thrombolysis (HR=8.5, 95% CI 1.7-41.7, p=0.008) and use of a bare-metal stent (HR=4.4, 1.1-17.0, p=0.034) were independent predictors of mortality. CONCLUSIONS: Our data suggest that in contemporary practice stenting for unprotected left main disease can be considered as an alternative treatment to surgery for selected patients. The results of randomised controlled trials are awaited.
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Angioplastia Coronária com Balão/mortalidade , Angioplastia Coronária com Balão/tendências , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/terapia , Idoso , Idoso de 80 Anos ou mais , Vasos Coronários/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tempo , Resultado do TratamentoRESUMO
Patients undergoing elective PCI are traditionally admitted overnight, however day case PCI cuts costs and has been proposed as a safe method for selected patients. We evaluated the success and long term clinical outcomes of day case percutaneous coronary intervention (PCI) for outpatients with stable angina. In total, 484 consecutive patients treated over a five year period with planned day case PCI were studied and followed up for 12 months. Successful PCI with same day discharge was performed in 463 patients (95.7%). There were 21 patients (4.3%) who required hospital admission. Reasons for failed discharge were hematoma formation (n=7, 1.4%), coronary dissection (n=4, 0.8%), post-procedural chest pain (n=3, 0.6%), prolonged procedure (n=2, 0.4%), and 1 each of acute stent thrombosis, coronary perforation, anaphylaxis, minor drug reaction and a functional study for untreated disease. One year follow up was complete for 439/484 (90.7%). At 12 months there were 6 hospitalizations for angina (1.2%, 95% CI 0.6-3.0%), 20 repeat revascularisations (4.1%, 95% CI 2.7-6.3%), 3 myocardial infarctions (0.6%, 95% CI 0.2-2.1%) and 2 deaths (0.4%, 95% CI 0.1-1.6%). Event free survival at 1 year follow up was 93.6% (95% CI 90.7-95.6%). Selecting patients for day case PCI is safe, and can achieve a high rate of success with excellent long term outcomes.
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Procedimentos Cirúrgicos Ambulatórios , Angina Pectoris/terapia , Angioplastia Coronária com Balão , Segurança , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do TratamentoRESUMO
We report the successful percutaneous closure of an iatrogenic atrial septal defect in a 71-year-old woman. The patient had undergone mitral valve replacement and coronary artery bypass grafting, followed by redo surgery to repair a para-valvular mitral leak. Post-operatively she remained significantly limited by dyspnoea. Repeat transoesophageal echocardiography documented a large iatrogenic atrial septal defect. The patient underwent percutaneous, trans-femoral closure of the defect using the Helex septal occluder (W.L. Gore, Newark, Delaware, USA) with dramatic clinical improvement.
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Comunicação Interatrial/etiologia , Comunicação Interatrial/terapia , Próteses Valvulares Cardíacas/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Idoso , Ponte de Artéria Coronária , Ecocardiografia Transesofagiana , Feminino , Humanos , Doença Iatrogênica , Falha de Prótese , ReoperaçãoRESUMO
We report the case of a 42-year-old female with proven anterior ischemia and an anomalous origin of the left main coronary artery (ALMCA) who underwent successful percutaneous coronary intervention (PCI) with intravascular ultrasound (IVUS) guidance. Angiographic and IVUS images demonstrate features unique to the ALMCA. The epidemiology, pathophysiology, evaluation and management options, including technical considerations for percutaneous intervention, are discussed. The ALMCA from the right sinus of Valsalva represents one of the few potentially serious congenital coronary artery anomalies. These patients are often young, have atypical presentation and carry a risk of sudden death. In combination with unfamiliar anatomy and pathophysiology, they pose serious diagnostic and therapeutic challenges. We present our experience in a patient who underwent successful PCI with IVUS guidance, and discuss the anatomy, pathophysiology, evaluation and treatment options for the ALMCA.
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Angioplastia Coronária com Balão/métodos , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/terapia , Ultrassonografia de Intervenção/métodos , Adulto , Angiografia Coronária , Diagnóstico Diferencial , Feminino , Seguimentos , HumanosRESUMO
OBJECTIVE: To review the procedures, results and follow-up of patients who underwent percutaneous device closure of a patent foramen ovale (PFO) during pregnancy. We report modifications made to the established technique that allowed absolute minimization of radiation exposure. Relevant management issues of this unusual presentation of cardiac disease in pregnancy are discussed. BACKGROUND: Stroke during or immediately prior to pregnancy is a catastrophic event. Paradoxical embolism may be more frequent due to the hypercoagulable state and increased incidence of venous thromboembolism. Treatment strategies must take into account the competing risks to mother and fetus. METHODS: Three patients, aged 34, 27, and 39, presented with ischemic neurological events during or immediately preceding pregnancy. Due to evidence of recurrent events or relative contraindication to anticoagulation they proceeded to percutaneous device closure during the second trimester. The Helex device (WL Gore and Associates) was used in all patients. Procedures were performed with local anesthesia under intra-cardiac echocardiography guidance. RESULTS: Successful closure was achieved with the Helex device in all three patients. Radiation doses, as assessed by dose area product, were 260, 58, and 19 cGy/cm(2), with estimated uterine (fetal) dose of <0.005 mGy, <0.001 mGy, and <0.0005 mGy. There were no peri-procedural complications. Despite one patient subsequently developing pre-eclampsia and another major post-partum hemorrhage all pregnancies were successful and free of further neurologic events. CONCLUSIONS: Percutaneous device closure of the PFO is a feasible option for selected patients with cryptogenic stroke believed secondary to paradoxical embolism. The procedure can be performed safely and effectively under local anesthesia using intra-cardiac echocardiography and with trivial fetal radiation exposure.
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Cateterismo/instrumentação , Comunicação Interatrial/terapia , Complicações Cardiovasculares na Gravidez/terapia , Adulto , Isquemia Encefálica/etiologia , Feminino , Comunicação Interatrial/complicações , Humanos , Gravidez , Doses de Radiação , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
An anomalous origin of the left circumflex is the most common congenital abnormality encountered in coronary angiography and it may selectively predispose to focal accelerated atherosclerotic disease. We report the case of a 54-year-old man who presented with non-ST elevation myocardial infarction and a characteristic retroaortic (proximal) culprit lesion in his anomalous circumflex artery. Intravascular ultrasound images illustrate the dynamic nature of the lumen compression. A "two wires-two vessel" angioplasty technique provided extra support and is recommended to facilitate successful anomalous circumflex percutaneous coronary interventions.