Carlos Campos

Comparison of acute gain and late lumen loss after PCI with bioresorbable vascular scaffolds versus everolimus-eluting stents: an exploratory observational study prior to a randomised trial

AIMS The study sought to compare the acute gain and two-year follow-up late lumen loss (LLL) between the Absorb bioresorbable vascular scaffold (BVS) and the analogous everolimus-eluting metallic stent (EES). The current analysis included all the patients recruited in the ABSORB Cohort B and SPIRIT II trials implanted with a single 3.0×18 mm device (Absorb BVS or EES) who underwent serial angiographic examinations at baseline and at two-year follow-up. The acute gain was defined as the difference between post- and preprocedural minimal lumen diameter (MLD). The in-stent/scaffold LLL was calculated as the difference in stent/scaffold segment between the post-procedural MLD and follow-up MLD. Thirty-three patients (33 lesions) implanted with the Absorb BVS, and 26 patients (28 lesions) implanted with the EES were studied. The acute gain was similar in the Absorb BVS group (1.23±0.38 mm) compared to the EES group (1.32±0.26 mm, p=0.29). The in-stent/scaffold LLL at two-year follow-up in the Absorb BVS group (0.26±0.19 mm) was also similar compared to the EES group (0.22±0.22 mm, p=0.29). Although the two groups had similar two-year clinical outcomes (major adverse cardiac events: Absorb BVS: 6.1% vs. EES: 0.0%), patients treated with the Absorb BVS exhibited a significantly lower two-year in-stent/scaffold MLD compared to the EES (2.02±0.26 mm vs. 2.22±0.34 mm, p=0.01). Although BVS and EES demonstrated similar two-year clinical outcomes, patients treated with the Absorb BVS exhibited a significantly lower two-year in-stent/scaffold MLD compared to patients treated with the EES. Appropriately powered randomised trials are necessary to confirm these exploratory results and evaluate their prognostic and clinical significance.

Insulin modulates cytokine release and selectin expression in the early phase of allergic airway inflammation in diabetic rats

BackgroundClinical and experimental data suggest that the inflammatory response is impaired in diabetics and can be modulated by insulin. The present study was undertaken to investigate the role of insulin on the early phase of allergic airway inflammation.MethodsDiabetic male Wistar rats (alloxan, 42 mg/Kg, i.v., 10 days) and controls were sensitized by s.c. injection of ovalbumin (OA) in aluminium hydroxide 14 days before OA (1 mg/0.4 mL) or saline intratracheal challenge. The following analyses were performed 6 hours thereafter: a) quantification of interleukin (IL)-1β, tumor necrosis factor (TNF)-α and cytokine-induced neutrophil chemoattractant (CINC)-1 in the bronchoalveolar lavage fluid (BALF) by Enzyme-Linked Immunosorbent Assay, b) expression of E- and P- selectins on lung vessels by immunohistochemistry, and c) inflammatory cell infiltration into the airways and lung parenchyma. NPH insulin (4 IU, s.c.) was given i.v. 2 hours before antigen challenge.ResultsDiabetic rats exhibited significant reduction in the BALF concentrations of IL-1β (30%) and TNF-α (45%), and in the lung expression of P-selectin (30%) compared to non-diabetic animals. This was accompanied by reduced number of neutrophils into the airways and around bronchi and blood vessels. There were no differences in the CINC-1 levels in BALF, and E-selectin expression. Treatment of diabetic rats with NPH insulin, 2 hours before antigen challenge, restored the reduced levels of IL-1β, TNF-α and P-selectin, and neutrophil migration.ConclusionData presented suggest that insulin modulates the production/release of TNF-α and IL-1β, the expression of P- and E-selectin, and the associated neutrophil migration into the lungs during the early phase of the allergic inflammatory reaction.

Myocardial homing after intrapericardial infusion of Bone Marrow Mononuclear Cells

Erika Branco1, Emerson Ticona Fioretto2, Rosa Cabral3, Carlos Alberto Sarmento Palmera4, Guilherme Buzon Gregores4, Angelo Joao Stopiglia4, Paulo Cesar Maiorka4, Pedro Alves Lemos5, Carlos Campos5, Celso Takimura5, Jose Antonio Franchini Ramires5, Maria Angelica Miglino4 Faculdade de Medicina Veterinaria da Universidade Federal Rural da Amazonia – UFRA1, Belem, PA; Universidade Federal do Sergipe – UFS2, Aracaju, SE; Universidade Feral do Piaui – UFPI3, Teresina, PI; Faculdade de Medicina Veterinaria e Zootecnia FMVZ/USP4, Sao Paulo, SP; Instituto do Coracao – Incor5, Sao Paulo, SP, Brasil

Stent coronário de liga cobalto-cromo concebido no Brasil: achados histológicos preliminares em modelo experimental porcino

SUMMARY Cobalt-Chromium Coronary Stent Conceivedin Brazil: Preliminary Histologic Findings inan Experimental Porcine Model Background: This study aims to evaluate, in an experimen-tal porcine model, a new and pioneer cobalt-chromiumthin-strut coronary stent conceived in Brazil. Also, it aimsto report the initial experience of a Brazilian center forpre-clinical validation of endovascular devices. Method: The new bare Cobalt-Chromium stent (Scitech ProdutosMedicos Ltda) was implanted in the coronary arteries oftwelve domestic pigs. The stent was designed in short rings(for increased homogeneity of vessel scaffolding), thin struts(75 µm) and inter-strut angle engineered to optimize theradial strength. The inter-ring connection was made by ashort and very thin link (65 µm) in a curved format, witha circumferential diameter of 6 mm for side branch access.Another two animals received conventional bare metalstents as controls (Driver®, Medtronic Inc., e Matrix®,Sahajanand Medical Technologies). After one month, theimplanted stents were excised for microscopic analysis.

Transcatheter aortic valve update 2013

Cumulative evidence has demonstrated that transcatheter aortic valve implantation (TAVI) constitutes an effective treatment option for patients with severe symptomatic aortic stenosis and a high operative risk. New valve designs and TAVI-enabling devices have simplified the procedure, reduced the risk of complications, and broadened the applications of this treatment. The global adoption of TAVI allows us to appreciate the advantages, potentialities and caveats of the technology, identify patients who would benefit from TAVI and stratify more accurately the risk of complications. The focus of this article is to discuss the advances in this field, present the current evidence, and highlight the developments and strategies proposed to address the limitations of TAVI treatment.

Comparison between two- and three-dimensional quantitative coronary angiography bifurcation analyses for the assessment of bifurcation lesions: A subanalysis of the TRYTON pivotal IDE coronary bifurcation trial

Three‐dimensional (3D) quantitative coronary angiography (QCA) provides more accurate measurements by minimizing inherent limitations of two‐dimensional (2D) QCA. The aim of this study was to compare the measurements between 2D and 3D QCA analyses in bifurcation lesions.

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.

Cost-effectiveness of percutaneous coronary intervention versus bypass surgery from a Dutch perspective.

Aims Recent cost-effectiveness analyses of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) have been limited by a short time horizon or were restricted to the US healthcare perspective. We, therefore, used individual patient-level data from the SYNTAX trial to evaluate the cost-effectiveness of PCI versus CABG from a European (Dutch) perspective. Methods and results Between 2005 and 2007, 1800 patients with three-vessel or left main coronary artery disease were randomised to either CABG (n=897) or PCI with drug-eluting stents (DES; n=903). Costs were estimated for all patients based on observed healthcare resource usage over 5 years of follow-up. Health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on Dutch life-tables was used to extrapolate the 5-year in-trial data to a lifetime horizon. Although initial procedural costs were lower for CABG, total initial hospitalisation costs per patient were higher (€17 506 vs €14 037, p<0.001). PCI was more costly during the next 5 years of follow-up, due to more frequent hospitalisations, repeat revascularisation procedures and higher medication costs. Nevertheless, total 5-year costs remained €2465/patient higher with CABG. When the in-trial results were extrapolated to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with gains in both life expectancy and quality-adjusted life expectancy. The incremental cost-effectiveness ratio (ICER) (€5390/quality-adjusted life year (QALY) gained) was favourable and remained <€80 000/QALY in >90% of the bootstrap replicates. Outcomes were similar when incorporating the prognostic impact of non-fatal myocardial infarction and stroke, as well as across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs. However, DES-PCI was economically dominant compared with CABG in patients with a SYNTAX Score ≤22 or in those with left main disease. In patients for whom the SYNTAX Score II favoured PCI based on lower predicted 4-year mortality, PCI was also economically dominant, whereas in those patients for whom the SYNTAX Score II favoured surgery, CABG was highly economically attractive (ICER range, €2967 to €3737/QALY gained). Conclusions For the broad population with three-vessel or left main disease who are candidates for either CABG or PCI, we found that CABG is a clinically and economically attractive revascularisation strategy compared with DES-PCI from a Dutch healthcare perspective. The cost-effectiveness of CABG versus PCI differed according to several anatomic factors, however. The newly developed SYNTAX Score II provides enhanced prognostic discrimination in this population, and may be a useful tool to guide resource allocation as well. Trial registration number Clinical trial unique identifier: NCT00114972 (http://www.clinical-trials.gov)

Infarto agudo do miocárdio complicado por choque cardiogênico: efeito da circulação colateral nos resultados da intervenção coronária percutânea primária - dados do registro InCor

INTRODUCAO: A presenca de circulacao colateral no contexto do infarto agudo do miocardio (IAM) pode exercer um fator de protecao, levando a menor area de infarto e melhor funcao ventricular. Este trabalho procurou examinar as caracteristicas clinicas dos pacientes com diferentes graus de circulacao colateral e a influencia desta na evolucao do IAM com supradesnivelamento de segmento ST (IAMCSST) complicado com choque cardiogenico a admissao hospitalar e tratados com intervencao coronaria percutânea (ICP) primaria. METODOS: Registro unicentrico que realizou seguimento prospectivo no periodo de 2001 a 2009, incluindo 105 pacientes divididos em dois grupos, de acordo com o grau de circulacao colateral: grupo 1, circulacao colateral graus 0/1 (n = 83); e grupo 2, circulacao colateral graus 2/3 (n = 22). As caracteristicas clinicas e angiograficas e os desfechos hospitalares foram comparados entre os grupos. RESULTADOS: Ambos os grupos foram semelhantes em relacao as caracteristicas clinicas, exceto pela menor media de idade (65,9 anos vs. 57,8 anos; P = 0,015) e maior tendencia ao tabagismo atual no grupo com colateral graus 2/3 (15,7% vs. 31,8%; P = 0,08). Quanto as caracteristicas angiograficas, nos individuos com colateral graus 2/3 houve maior frequencia de lesoes/paciente (1,3 lesao vs. 1,8 lesao; P = 0,02) e maior acometimento de bifurcacao coronaria (18,5% vs. 36,4%; P = 0,03). Na evolucao intra-hospitalar ficou evidenciada menor mortalidade nos pacientes com circulacao colateral exuberante (49,4% vs. 27,3%, risco relativo de 0,55; P = 0,05). CONCLUSOES: Em pacientes com IAMCSST e choque cardiogenico tratados com ICP primaria a presenca de circulacao colateral pode favorecer um melhor prognostico na evolucao intra-hospitalar.

Development of a closed-artery catheter-based myocardial infarction in pigs using sponge and lidocaine hydrochloride infusion to prevent irreversible ventricular fibrillation

The objectives of this study were to develop a robust, homogeneous, viable and inexpensive model of closed‐artery catheter‐based model of myocardial infarction (MI) in pigs without major cardiac dysfunction. Suitable animal models that mimic human cardiovascular conditions are of paramount importance to understand the effects of novel therapeutic strategies to improve tissue perfusion and prevent cardiac deterioration post‐MI. Pigs (N = 21, BW = 17 ± 1 kg) receiving continuous iv lidocaine hydrochloride were subjected to percutaneous intracoronary implant of foam sponge into the proximal left circumflex coronary artery. Intraprocedure mortality was 23.8%. ST segment elevation and increased serum Troponin T and CK‐MB were documented in all animals. Thirty days after occlusion, echocardiography (95% IC [9.3–12.4%]) and anatomopathological (95% CI [9.3–12.6%]) analyses confirmed a significant and reproducible MI. Taken together, we provide evidence for a suitable closed‐artery catheter‐based method to produce MI in pigs accompanied by tissue hypoperfusion and absence of overt heart failure.