Antonia Petrizzo

Randomized trial of direct coronary angioplasty versus intravenous streptokinase in acute myocardial infarction

OBJECTIVES The objective of this study was to obtain preliminary data on the relative clinical utility of direct coronary angioplasty compared with that of intravenous thrombolytic therapy for patients with acute myocardial infarction. BACKGROUND The relative merits of intravenous thrombolytic therapy and direct coronary angioplasty as treatment for acute myocardial infarction are incompletely understood, and randomized trials of these treatments have been extremely limited. METHODS One hundred patients with ST segment elevation presenting to a single high volume interventional center within 6 h of the onset of chest pain were randomized to receive either streptokinase (1.2 million U intravenously over 1 h) or immediate catheterization and direct coronary angioplasty. Patients were excluded for age > or = 75 years, prior bypass surgery, Q wave infarction in the region of ischemia or excessive risk of bleeding. All patients were then treated with aspirin (325 mg orally/day) and heparin (1,000 U intravenously/h) for 48 h until catheterization was performed to determine the primary study end point, namely, infarct-related artery patency at 48 h. Secondary end points were in-hospital death, left ventricular ejection fraction at 48 h and time to treatment. RESULTS There was no difference in the baseline characteristics of the two treatment groups. Overall patient age was 56 +/- 10 years, 83% of patients were male, 11% had prior infarction, 40% had anterior infarction and 97% were in Killip class I or II. Although time to treatment was delayed in the angioplasty group (238 +/- 112 vs. 179 +/- 98 min, p = 0.005), there was no difference in 48-h infarct-related artery patency or left ventricular ejection fraction (patency 74% vs. 80%; ejection fraction 59 +/- 13% vs. 57 +/- 13%; angioplasty vs. streptokinase, p = NS for both). There were no major bleeding events, and the mortality rate with angioplasty (6%) and streptokinase (2%) did not differ (p = NS). CONCLUSIONS These results suggest that intravenous thrombolytic therapy might be preferred over coronary angioplasty for most patients because of the often shorter time to treatment.

Avaliação da anastomose de artéria torácica interna esquerda com artéria interventricular anterior pela ecodopplercardiografia

OBJETIVO: Avaliar o valor do ecocardiograma Doppler(ECO) transtoracico na identificacao de perviabilidade da anastomose entre arteria toracica interna esquerda (ATIE) e interventricular anterior, realizada pela tecnica de revascularizacao miocardica pela minitoracotomia sem circulacao extracorporea. METODOS: Estudaram-se os primeiros 12 pacientes, consecutivos, no periodo de pos-operatorio intra-hospitalar pelo ECO, utilizando-se transdutores de 5MHz, pela via paraesternal esquerda, preferencialmente. Foram analisadas velocidades maximas e integrais de velocidade dos componentes sistolico e diastolico das curvas espectrais de fluxo Doppler. Todos pacientes foram submetidos a cinecoronariografia, enquanto hospitalizados. RESULTADOS: O ECO foi exequivel em 93% dos pacientes. Nos com anastomose pervia (6/7), observou-se ao estudo Doppler amplo componente diastolico (padrao A). Naqueles com anastomose obstruida (4/4) o padrao observado foi de predominio sistolico (padrao B) (p=0,003*). CONCLUSAO: O ECO da ATIE anastomosada com a arteria interventricular anterior, apos cirurgia de revascularizacao miocardica pela tecnica de minitoracotomia, permitiu caracterizar precocemente, com precisao, a perviabilidade da anastomose.

Modificações evolutivas da necessidade de cirurgia de revascularização miocárdica de emergência em indivíduos submetidos a intervenção coronária percutânea: análise de 9.938 pacientes

BACKGROUND: Percutaneous coronary interventions (PCI) in centers without cardiac surgery represent a real option in the current context of interventional cardiology. The purpose of this study was to evaluate changes in the incidence and indications for coronary artery bypass grafting in patients undergoing PCI from 1992 to 2005 METHOD: Data from 9,938 patients undergoing PCI in two centers were divided into three groups: pre-stent period, from 1992 to 1996 (n = 2,500), intermediate period, from 2002 to 2003 (n = 3,711) and more recent period, from 2004 to 2005 (n = 3,727) RESULTS: Since the advent of stents, an older population (58.2 ± 10.7 years vs. 62.7 ± 11.7 years vs. 67.8 + 11.6 years; P = 0.01), with more complex type B2/C lesions (52.2% vs. 72.7% vs 79%; P < 0.01) is being treated, with a lower rate of acute vessel occlusion (7.8% vs. 1.7% vs. 1.1%; P < 0.01), emergency coronary artery bypass grafting (1.2% vs. 1,1% vs. 0.7%; P < 0.01) and mortality (3.3% vs. 2.2% vs. 2%; P < 0.01). Predictors of the need of emergency bypass surgery were multivessel disease [odds ratio (OR) 3.42, 95% confidence interval (95% CI) 1.75-6.7), acute myocardial infarction (OR 3.65, 95% CI 2.3-5.8) and lesion complexity [type B2/C, American Heart Association/American College of Cardiology - AHA/ACC (OR 3.27, 95% CI 1.6-6.75)]. The use of stents, however, conferred a protective effect against the need of emergency bypass surgery (OR 0.58, 95% CI 0.4-0.85) CONCLUSION: Advances in technology, devices and adjunctive pharmacotherapy have improved PCI, reducing the need of emergency coronary artery bypass grafting.

Revascularização do miocárdio minimamente invasiva

There is a tendency in all fields of surgery to move towards less invasive surgical techniques in recent years. The end point of this study was to analyse the possibility of myocardial revascularization through a minimum left thoracotomy approach. From September 1995 till March 1996 we operated on 19 patients that had isolated lesion of interventricular anterior artery (IAA) and/or diagonal. The anastomoses were made by a left minor thoracotomy, opening the pleura at the 4o intercostal space. Through this incision we dissected the thoracic internal artery with ligation of only few branches. The anastomoses were performed without extracorporeal circulation, with a simple interruption of coronary blood flow. At the second postoperative day we studied the patients with angiography and transthoracic echo-Doppler, to verify patency and flow. All patients had uneventful recovery without major complications. Angiography was made in 16 out of 19 and showed patency in 13. The 3 patients with graft occlusion were reoperated on without complications. The presented technique did not involve ligation of the intercostal branches, however these branches were not demonstrated by angiography. Transthoracic Doppler showed good relationship with angiographic findings. The initial results with this technique suggest that we can have another option of minimum invasive myocardial revascularization for selected patients.