André Gasparini Spadaro

Intravascular Ultrasound Guidance to Minimize the Use of Iodine Contrast in Percutaneous Coronary Intervention: The MOZART (Minimizing cOntrast utiliZation With IVUS Guidance in coRonary angioplasTy) Randomized Controlled Trial

Objective To evaluate the impact of IVUS guidance on the final volume of contrast agent utilized in patients undergoing PCI.

Evolução hospitalar de pacientes submetidos a assistência circulatória com balão intra-aórtico durante intervenção coronária percutânea de alto risco: registro InCor

ABSTRACT In-Hospital Outcomes of Patients Submitted toCirculatory Support with Intra-Aortic BalloonPump During High Risk Percutaneous CoronaryIntervention: InCor Registry Background: The intra-aortic balloon pump (IABP) has beenused for decades as a circulatory support device, beingrecommended in most guidelines, despite poor evidence ofmortality reduction. The purpose of this study was to evaluatethe use of IABP as an adjunct therapy in percutaneouscoronary intervention (PCI). Methods: Single center registryanalyzing in-hospital outcomes of 134 consecutive patientssubmitted to IABP during high risk PCI or in the presenceof cardiogenic shock. Results: Mean age was 64.7 + 12.5years and 67.9% were males. The population presentedhigh-risk features, with 33.5% of diabetic patients, 73.1%treated in the presence of myocardial infarction, 68.6%with three-vessel disease and left ventricular ejection fractionof 38.6 + 16.1%. TIMI 2/3 flow was obtained in 86.4% ofthe cases and 1.6 + 0.6 lesion/patient was treated. Therewere 18 (13.4%) reinfarctions, of which 9 (6.7%) were dueto stent thrombosis, 2 (1.4%) patients were referred forCABG and 16 (11.9%) for a new PCI. Hospital mortalitywas 61.2% and the major adverse cardiac events (MACE)rate was 67.2%. By multivariate analysis, predictors ofmortality were: age > 65 years, prior PCI, need of dialysisand three-vessel disease. Predictors of survival were: normalventricular function, TIMI 2/3 flow at the end of the procedureand IABP utilization > 72 hours.

Resultados clínicos iniciais do primeiro stent de cromo-cobalto concebido no Brasil

Initial Clinical Results of the First Cobalt-Chromium Stent Designed in Brazil Background: Thin-strut cobalt-chromium stents have greater flexibility and probably have less neointimal proliferation than stainless steel stents. Methods: The Cronus (Scitech Produtos Medicos, Goiânia, Brazil) registry is an international, non-randomized, prospective study designed to evaluate the efficacy and safety of a novel thin-strut cobalt-chromium stent in patients with coronary artery disease. A total of 69 lesions were treated in 53 patients included in this analysis. Results: The device success was 98.5%. Mean late luminal loss was 0.7 ± 0.5 mm, binary restenosis occurred in 15% and target vessel revascularization in 11.3% of the cases. The incidence of major adverse cardiac events (death, myocardial infarction or target vessel revascularization) was 24.4% after 317 ± 80 days of follow-up. Conclusion: Our initial results demonstrate that the novel Cronus stent proved to be safe and effective, with clinical results similar to other available thin-strut stents. DESCRIPTORS: Stents. Angioplasty, transluminal, percutaneous coronary. Prostheses and implants.

Caracterização e impacto clínico tardio do no-reflow associado a intervenção coronária percutânea primária vs. eletiva

INTRODUCAO: Apesar dos grandes avancos alcancados pela cardiologia intervencionista, o fenomeno do no-reflow ainda ocorre durante as intervencoes coronarias percutâneas (ICP) e esta associado a pior prognostico. O objetivo deste estudo foi caracterizar os perfis clinico, angiografico e do procedimento de pacientes com no-reflow, alem de avaliar seu impacto clinico tardio. METODOS: Analisamos, no periodo de janeiro de 2004 a fevereiro de 2009, todos os pacientes submetidos a ICP no Instituto do Coracao (InCor), que em qualquer momento da intervencao apresentaram no-reflow, mesmo que transitoriamente. Os pacientes foram divididos em dois grupos: no-reflow de reperfusao (associado a ICP primaria) e no-reflow de intervencao (associado a ICP eletiva). A probabilidade de obito foi estimada pelo metodo de Kaplan-Meier e a regressao de Cox foi utilizada para identificar seus preditores. RESULTADOS: Foram avaliados 132 pacientes consecutivos, 81 no grupo no-reflow de reperfusao e 51 no grupo no-reflow de intervencao. O sucesso do procedimento foi obtido em 83,5% da populacao total (80,2% vs. 90,2%, respectivamente; P = 0,149). A probabilidade de mortalidade tardia foi estimada em 38,6%, sendo maior no grupo de no-reflow de reperfusao (55,8% vs. 11,1%; P = 0,005). Na analise multivariada, somente o sexo feminino [hazard ratio (HR) 2,5, intervalo de confianca de 95% (IC 95%) 1,22-5,14; P = 0,027) e a doenca pulmonar obstrutiva cronica (HR 9,3, IC 95% 1,45-60,14; P = 0,027) foram preditores independentes de mortalidade, enquanto o uso previo de estatina foi um fator de protecao (HR 0,15, IC 95% 0,05-0,48; P = 0,002). CONCLUSOES: O fenomeno de no-reflow foi associado a elevados indices de insucesso do procedimento e mortalidade tardia, principalmente quando associado a angioplastia primaria.

Left Main Ostial Compression in a Patient with Pulmonary Hypertension: Dynamic Findings by IVUS

Patient: Female, 39 Final Diagnosis: Idiopathic pulmonary arterial hypertension Symptoms: Chest pain Medication: — Clinical Procedure: Percutaneous coronary intervention Specialty: Cardiology and Pulmonology Objective: Rare co-existance of disease or pathology Background: Pulmonary artery dilatation is a common feature among patients with severe pulmonary hypertension. Left main coronary artery extrinsic compression by an enlarged pulmonary artery is a rare complication and a potential cause for chest pain and sudden cardiac death in patients with pulmonary hypertension. This situation is very rare and few reports have described it. Currently, the appropriate management of these patients remains unknown. Case Report: In the present report we describe the case of a 39-year-old woman who presented with a 2-year history of cardiac symptoms related to exercise. The patient underwent a 64-slice multidetector computed tomography (MDCT) coronary angiography, which showed left main coronary artery (LMCA) compression by a markedly enlarged pulmonary artery trunk (44 mm), without intraluminal stenosis or coronary artery calcium, as determined by the Agatston score. This compression was considered to be the cause of the cardiac symptoms. To confirm and plan the treatment, the patient underwent cardiac catheterization that confirmed the diagnosis of pulmonary hypertension and LMCA critical obstruction. Taking into account the paucity of information regarding the best management in these cases, the treatment decision was shared among a “heart team” that chose percutaneous coronary intervention with stent placement. An intra-vascular ultrasound was performed during the procedure, which showed a dynamic compression of the left main coronary artery. The intervention was successfully executed without any adverse events. Conclusions: This case illustrates dynamic compression of the LMCA by IVUS, visually demonstrating the mechanism of the intermittent symptoms of myocardial ischemia in this kind of patient. It also shows that percutaneous stenting technique may be an appropriate treatment for this unusual situation.

Desfechos tardios da intervenção coronária percutânea com stent farmacológico em pontes de veia safena: dados do registro InCor

BACKGROUND: The safety and efficacy of drug-eluting stents in the treatment of saphenous vein graft (SVG) lesions remains controversial. This study assessed the late follow-up of patients with SVG lesions treated with drug-eluting stents. METHODS: Single center registry including patients undergoing SVG interventions using drug-eluting stents (n = 82), without clinical or angiographic exclusion criteria, from 2003 to 2009. The rates of major adverse cardiac events (MACE), death, acute myocardial infarction (AMI), target vessel revascularization (TVR) and stent thrombosis were evaluated. RESULTS: Mean age was 67.8 ± 10.2 years, most of them were male (85.4%), 40.2% were diabetic and 52.4% had stable angina. An average of 1.45 ± 0.5 stents per patient were implanted and CypherTM was the stent used in most of the cases (61%). Stent diameter was 3.22 ± 0.39 mm and stent length was 20.1 ± 7.3 mm. Angiographic success rate was 96.3%. In the 4.1-year follow-up, the rate of MACE was 28%, death 6%, AMI 19.5% and TVR 18.2%. There were two cases of definitive or probable stent thrombosis (2.4%) within the follow-up period. CONCLUSIONS: Long-term follow-up showed high MACE rates in patients with SVG lesions treated with drug-eluting stents, probably due to the accelerated atherosclerosis that develops within the grafted vein conduits.

Stents convencionais de aço inoxidável vs. cromo-cobalto: impacto clínico da liga metálica no cenário atual - registro InCor

ABSTRACT Stainless Steel versus Cobalt-ChromiumBare Metal Stents: Clinical Impact of theMetal Alloy in a “Real World” Scenario –InCor Registry Background: Years ago studies demonstrated that the use ofcobalt-chromium stents with thinner struts significantly reducedcoronary restenosis when compared to conventional stainlesssteel stents available at the time. Since then, stents with struts< 100 µm and different metal alloys are available for clinicaluse. The objective of this study was to assess differences inthe clinical outcomes of patients undergoing percutaneouscoronary intervention (PCI) with thin strut stents and differentmetal alloys. Methods: Single center registry comparing theresults of patients undergoing PCI with stainless steel stents(n = 135) vs. cobalt-chromium bare metal stents (n = 181).The primary endpoint was the occurrence of major adversecardiac events (MACE), defined by death, acute myocardialinfarction (AMI) or target vessel revascularization (TVR) in thelate follow-up.

Perfil de segurança dos stents farmacológicos nas síndromes coronárias agudas: dados do Registro INCOR

BACKGROUND: Drug-eluting stents are a great advance in the treatment of coronary disease. However, their use in patients with acute coronary syndromes has been the subject of intense scientific debate. METHODS: 910 consecutive patients treated with at least one drug-eluting stent between May 2002 and September 2006 were enrolled in the present analysis. The patients were assigned to 2 groups according to their clinical condition at the time of admission: 1) Stable group (635 patients with stable angina) and 2) Acute group (275 patients with NSTEMI). We analyzed the clinical and angiographic characteristics as well as the occurrence of late adverse events. RESULTS: The clinical characteristics of the groups were similar, except for the highest incidence of smokers in the acute group and previous percutaneous intervention in the stable group. After 588 days (median follow-up period), the stable and acute groups had similar rates of re-infarction (2.8 vs. 5.0%; p = 0.1), target vessel revascularization (6.0 vs. 7.7%; p = 0.4), death (4.5 vs. 6.5%; p = 0.2) and composite major adverse cardiac events (9.9 vs. 11.9%; p = 0.4), respectively. However, the occurrence of in-stent thrombosis was more frequent in patients with acute coronary diseases (1.4 vs. 4.4%; p = 0.02), mainly due to the occurrence of thrombosis within the first year after implantation (1.1 vs. 4.4%; p = 0.01). CONCLUSION: Drug-eluting stents have shown a good safety profile in patients with acute coronary syndromes compared to those with chronic coronary disease, despite the higher incidence of late in-stent thrombosis.

Does Ad Hoc Coronary Intervention Reduce Radiation Exposure? - Analysis of 568 Patients.

Background Advantages and disadvantages of ad hoc percutaneous coronary intervention have been described. However little is known about the radiation exposure of that procedure as compared with the staged intervention. Objective To compare the radiation dose of the ad hoc percutaneous coronary intervention with that of the staged procedure Methods The dose-area product and total Kerma were measured, and the doses of the diagnostic and therapeutic procedures were added. In addition, total fluoroscopic time and number of acquisitions were evaluated. Results A total of 568 consecutive patients were treated with ad hoc percutaneous coronary intervention (n = 320) or staged percutaneous coronary intervention (n = 248). On admission, the ad hoc group had less hypertension (74.1% vs 81.9%; p = 0.035), dyslipidemia (57.8% vs. 67.7%; p = 0.02) and three-vessel disease (38.8% vs. 50.4%; p = 0.015). The ad hoc group was exposed to significantly lower radiation doses, even after baseline characteristic adjustment between both groups. The ad hoc group was exposed to a total dose-area product of 119.7 ± 70.7 Gycm2, while the staged group, to 139.2 ± 75.3 Gycm2 (p < 0.001). Conclusion Ad hoc percutaneous coronary intervention reduced radiation exposure as compared with diagnostic and therapeutic procedures performed at two separate times.

Early Removal of the Arterial Sheath After Percutaneous Coronary Intervention Using the Femoral Approach: Safety and Efficacy Study

ABSTRACT Introduction We evaluated the safety and efficacy of protamine administration, guided by activated clotting time, for the immediate femoral arterial sheath removal in patients undergoing percutaneous coronary intervention with unfractionated heparin in order to propose an algorithm for clinical practice. Methods Prospective study with consecutive patients with stable angina or low-to-moderate risk acute coronary syndrome. We compared patients with an early removal of the arterial sheath to those whose sheath removal was based on a standard protocol. Results The early removal group (n = 149) had lower access manipulation time than the conventional group (58.3 ± 21.4 minutes vs. 355.0 ± 62.9 minutes; p p p = 0.49). There was no stent thrombosis during hospitalization and no significant differences in the incidence of major vascular or bleeding events. The incidence of other bleeding events leading to a prolonged in-hospital length of stay was lower in the early removal group (1.3% vs. 5.1%; p = 0.05). Conclusions: The selective use of an approach for immediate femoral sheath removal, based on activated clotting time guidance and protamine administration, is a safe and effective option in patients undergoing percutaneous coronary intervention by femoral access.