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2.
Front Cardiovasc Med ; 8: 719405, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34513958

RESUMO

Background: Failure of the native aortic valve and degenerative anatomy of ascending aorta in patients with previous Tirone-David operation may represent a clinical challenge, because sometimes the risk of reoperation is prohibitive. Case: We described the case of a patient suffering from severe aortic valve regurgitation and pseudoaneurysm of the aortic arch, 6 years after cardiac surgery operation. The aim of this clinical case was to assess if the complex anatomy of aortic pseudoaneurysm and aortic root geometry can be accurately reproduced from contrast-enhanced computed tomography scan into a three-dimensional (3D) printed model. Based on this procedural method, with the aid of transesophageal 3D ultrasound, we efficaciously treated the patient percutaneously with a combination of transcatheter occluder device plus microcoil embolization and transfemoral aortic valve implantation. The patient was free from complications and the need to redo cardiac surgery. Conclusion: To the best of our knowledge, this is the first description of two simultaneous complications and their staged treatment in a patient with previous aortic valve-sparing operation. This is a useful report in a single 3D model applying such specific technology to these two simultaneous clinical settings.

3.
Neurol Sci ; 42(1): 101-109, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33244742

RESUMO

OBJECTIVE: Systematic reviews suggest that patent foramen ovale closure (PFOc) is performed percutaneously with low complication rates. We did a network meta-analysis (NMA) comparing devices for PFO closures, evaluating safety and efficacy of transcatheter PFOc in preventing neurological events in patients with stroke when compared with medical therapy (MT), and assessing risk of atrial fibrillation (AF). METHODS: We searched 3 databases (MEDLINE, EMBASE, CENTRAL/CCTR) identifying six randomized controlled trials from 2012 until December 2019. We performed a Bayesian NMA; number-needed-to-treat and number-needed-to-harm were derived by applying the estimated odds ratios (ORs). The likelihood of being helped or harmed (LHH) was evaluated to estimate the risk-effectiveness balance. RESULTS: The 3560 patients allocated to PFOc were less subject to a stroke than patients with MT. The overall ORs of PFOc versus MT were 0.41 with fixed-effects, and 0.22 with random-effects model. NMA proves that PFOc induces AF episodes significantly higher than MT, even when analysis is limited to only new episodes of "serious AF." LHH (0.68 fixed-effects, 0.79 random-effects) showed that strokes saved are less than cases of AFs added. By considering only serious AF, strokes saved are higher than serious AFs induced by the PFOc (LHH was 3.46 and 4.00 respectively). CONCLUSIONS: NMA supported PFOc in patients with cryptogenic stroke, confirming that devices are better than MT, but increase the risk of AF by over 2/4 times (serious or unserious AF). Considering serious AFs (real risky clinical condition), patients have more advantages in being treated, since LHH is ≥ 3-4.


Assuntos
Fibrilação Atrial , Forame Oval Patente , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Teorema de Bayes , Forame Oval Patente/complicações , Forame Oval Patente/epidemiologia , Forame Oval Patente/terapia , Humanos , Metanálise em Rede , Fatores de Risco , Prevenção Secundária , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
4.
Cerebrovasc Dis ; 49(2): 124-134, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32289794

RESUMO

BACKGROUND: Randomized-controlled trials (RCTs) reported a finding on the safety and efficacy of percutaneous patent foramen ovale (PFO) closure to prevent stroke recurrence. It showed that the Amplatzer (AMP) device appears to be superior to medical therapy (MT) in preventing strokes and episodes of atrial fibrillation (AF), than other devices. We performed a network meta-analysis (NMA) to evaluate the closure of PFO in preventing subsequent neurological events while investigating the results obtained by specific devices. METHODS: We searched 3 databases (MEDLINE, EMBASE, CENTRAL/CCTR) and identified 6 RCTs until March 2019. We performed an NMA and used pooled ORs. Analyses were done in NetMetaXL1.6-WinBUGS1.4. RESULTS: Six RCTs with 3,560 patients (mean age 45.2-46.2 years) were included in the present NMA. Depending on the device, 4 groups of patients were compared with MT: 1,889 patients undergoing PFO closure were significantly less likely to experience a stroke than 1,671 patients treated with MT (ORs 0.41; 95% Cr.I. 0.27-0.60 with fixed-effects model and ORs 0.22; 95% Cr.I. 0.05-0.70 with random-effects model). The patients with AMP showed a similar risk than those treated with Helex/Cardioform (HLX/CF) or with a group of 11 multiple devices. This suggests the equality between the 2 most currently used devices. When assessing TIA and, for the safety analysis, major bleeding, both models confirm no significant difference between any devices and MT. PFO closure increased the risk of new-onset AF: MT induces AF significantly less than all the devices. In favor of the AMP, there is a reduced number of cases of AF versus MT; however, no device superiority has been established in comparing HLX/CF and other devices in a random effect model. CONCLUSIONS: Our NMA provides evidence in favor of PFO closure with all the devices currently in use. We can conclude that these devices are better than MT, but not that 1 device is better than the rest in reducing stroke recurrences and AF episodes in the follow-up.


Assuntos
Cateterismo Cardíaco/instrumentação , Embolia Paradoxal/prevenção & controle , Forame Oval Patente/terapia , Embolia Intracraniana/prevenção & controle , Ataque Isquêmico Transitório/prevenção & controle , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Teorema de Bayes , Cateterismo Cardíaco/efeitos adversos , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Metanálise em Rede , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento , Adulto Jovem
5.
J Cardiovasc Med (Hagerstown) ; 10(5): 401-5, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-19449455

RESUMO

PURPOSE OF REVIEW: To evaluate the course of migraine in migraine headache patients undergoing patent foramen ovale (PFO) transcatheter closure. BACKGROUND: Migraine has an important impact on the quality of life, and it seems to be one of the most disabling medical illnesses. In several studies, a high prevalence of right-to-left shunt has been described in patients with migraine, especially migraine with aura. The presence of right-to-left shunt, whatever the mechanism, may be the most potent trigger of migraine attacks in both migraine with aura and migraine without aura and the main determinant of aura in migraine with aura. METHODS: A cohort of 42 patients (nine men/33 women; mean age 39 +/- 11.2 years), current migraineurs, underwent PFO percutaneous closure in our centre between January 2004 and December 2007. All patients rated the severity of their migraine preoperatively and 6 months postoperatively, indicating the frequency, duration, and intensity of the attacks and the occurrence of the aura in the prodromal phase, during the past 6 months, according to the migraine severity score. RESULTS: Baseline severity of migraine was higher in migraine with aura patients than in migraine without aura ones (8.8 vs. 7.5; P = 0.037). The resolution of migraine was verified in 11 patients (26%) after the closure of the PFO. A reduction in the frequency of the attacks (>=50%) was observed in 22 patients (52%). Multiple logistic regression analysis showed that the improvement in migraine with aura and migraine without aura was independent of migraine type, sex, age, cerebrovascular risk factors and cerebrovascular events, type of cardiac defect, and thrombophilic conditions. DISCUSSION: The consistent observations of this and other studies are provocative and worthy of evaluation with a prospective randomized trial using objective measures of migraine frequency and severity. However, it seems too early to recommend PFO closure for all patients who suffer from migraine until the results of ongoing large randomized trials are available.


Assuntos
Cateterismo Cardíaco , Forame Oval Patente/terapia , Transtornos de Enxaqueca/prevenção & controle , Enxaqueca com Aura/prevenção & controle , Seleção de Pacientes , Adulto , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/fisiopatologia , Hemodinâmica , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/etiologia , Transtornos de Enxaqueca/fisiopatologia , Enxaqueca com Aura/etiologia , Enxaqueca com Aura/fisiopatologia , Guias de Prática Clínica como Assunto , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
6.
J Invasive Cardiol ; 20(11): E316-9, 2008 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18987409

RESUMO

Percutaneous coronary intervention (PCI) is routinely performed in patients with non-ST elevation acute coronary syndromes after pretreatment with clopidogrel and periprocedural administration of unfractionated heparin on a weight-adjusted basis. Although activated clotting time (ACT) monitoring is encouraged to verify the adequacy of anticoagulation during the procedures, this is not a common practice in many laboratories. The authors describe 4 cases of patients with bifurcation lesions involving the left anterior descending coronary artery, who developed periprocedural thrombosis with acute transmural ischemia. All patients had inadequate ACT measurements, despite conventional heparin dosage and ongoing clopidogrel treatment. In order to achieve complete anticoagulation, patients were switched to bivalirudin, which determined a prompt effect on measured ACT. This therapeutic regimen, coupled with further intervention, allowed resolution of the thrombotic complication without bleeding. This report suggests the feasibility of a strategy of bivalirudin use in patients who have some degree of heparin 'resistance' in the setting of complicated PCI.


Assuntos
Síndrome Coronariana Aguda/terapia , Angioplastia Coronária com Balão/efeitos adversos , Anticoagulantes/administração & dosagem , Trombose Coronária/tratamento farmacológico , Hirudinas/administração & dosagem , Fragmentos de Peptídeos/administração & dosagem , Idoso , Trombose Coronária/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/administração & dosagem , Resultado do Tratamento
7.
J Cardiovasc Med (Hagerstown) ; 7(9): 706-10, 2006 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16932086

RESUMO

BACKGROUND: Right ventricular function may be reduced in patients with idiopathic dilated cardiomyopathy (IDC). The prognostic implications of right ventricular dysfunction have not been investigated in this group of patients. METHODS: In a series of 120 consecutive patients with IDC [defined as a left ventricular ejection fraction (LVEF) < 55%, normal coronary arteries and no other causes for left ventricular dysfunction], right ventricular function was prospectively evaluated by means of angiocardiography at the time of catheterization. A head-to-head comparison of ventricular volumes, ejection fraction, end-diastolic pressure, stroke work index and end-systolic pressure/volume ratio of the left and right ventricle was performed according to the Cox's proportional hazard method for the pre-defined end-point of transplant-free survival. RESULTS: In the study population, LVEF was 31 +/- 11% and right ventricular ejection fraction (RVEF) was 34 +/- 10%. After a mean follow-up of 30 months (range 12-120 months), 26 patients died (22%) and 14 (12%) underwent heart transplantation. At univariate analysis, all the above mentioned parameters were significantly (P < 0.0001) associated with outcome except left and right ventricular end-systolic pressure/volume ratio. At multivariate analysis, independent predictors of transplant-free survival were RVEF (P = 0.001), right ventricular stroke work index (P = 0.015), right ventricular end-diastolic volume (P = 0.034) and left ventricular end-diastolic volume (P = 0.048), but not LVEF. The same relation holds true considering the end point of total mortality. CONCLUSIONS: Parameters of right ventricular function are strong predictors of survival in IDC, even in patients enrolled over a wide range of LVEFs. The present study suggests that right ventricular function should be evaluated in patients with IDC. A large non-invasive based study on right ventricular function in IDC appears to be warranted.


Assuntos
Cardiomiopatia Dilatada/fisiopatologia , Disfunção Ventricular Direita/etiologia , Adulto , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/mortalidade , Angiografia Coronária , Feminino , Transplante de Coração , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Volume Sistólico , Disfunção Ventricular Esquerda/etiologia
8.
J Invasive Cardiol ; 18(4): E134-6, 2006 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-16723747

RESUMO

The authors describe primary coronary intervention consisting of direct stenting after abciximab administration in a case of acute anterior myocardial infarction occurring in a heart transplant recipient with triple-vessel disease. Primary success was obtained and the patient survived to a one-year angiographic follow up which showed persistent coronary patency. This is the first report concerning the use of abciximab in primary stenting for acute myocardial infarction in allograft coronary artery disease.


Assuntos
Anticorpos Monoclonais/uso terapêutico , Anticoagulantes/uso terapêutico , Eletrocardiografia , Transplante de Coração/efeitos adversos , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/terapia , Stents , Abciximab , Doença Aguda , Idoso , Angiografia Coronária , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Período Pós-Operatório
9.
Ital Heart J ; 5(10): 749-54, 2004 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-15626271

RESUMO

BACKGROUND: Recent studies evaluated the technique of direct coronary stenting as compared to stenting-after-predilation in selected anatomic and clinical settings. However, the impact of direct stenting in routine interventional practice remains poorly elucidated. METHODS: From April 1999 to March 2001, all percutaneous coronary interventions performed at our Center were prospectively analyzed to determine the frequency of direct stenting, the success rate and the variables associated with its utilization. RESULTS: 1151 lesions were treated in 835 procedures. Stenting was attempted in 835/1151 lesions (72.5%), 309 (37%) with direct stenting and 526 (63%) with stenting-after-predilation. Direct stenting was successful in 300/309 (97%) and stenting-after-predilation in 515/526 (98%). The success rate of direct stenting was significantly lower in small vessels (< or = 2.75 mm) (89.2 vs 98.5%, p = 0.005). Patients treated with direct stenting were younger (63 +/- 11 vs 65 +/- 11 years, p = 0.024). Direct stenting was preferentially used in saphenous vein grafts and at the ostium of the left anterior descending coronary artery, while it was avoided in bifurcation lesions and with increasing calcium burden. Operators with a caseload > 140 interventions per year were significantly more likely to perform direct stenting than less experienced operators (p = 0.017). In direct stenting, the total contrast medium and the fluoroscopy and procedural times were all significantly (p < 0.0001) lower than those observed in case of stenting-after-predilation. CONCLUSIONS: Direct coronary stenting is currently performed in about one third of the overall caseload. Variables pertaining to the operator's experience, lesion morphology and length, vessel size, and the clinical presentation are all important factors determining the selection of candidates suitable for direct stenting.


Assuntos
Angioplastia Coronária com Balão/métodos , Isquemia Miocárdica/terapia , Stents/estatística & dados numéricos , Idoso , Angina Pectoris/terapia , Angioplastia Coronária com Balão/estatística & dados numéricos , Bases de Dados Factuais , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/epidemiologia , Estudos Prospectivos , Radiografia , Volume Sistólico/fisiologia
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