Egas Armelin

Lesão no segmento proximal da artéria coronária descendente anterior: resultados entre o tratamento cirúrgico (mamária) e o percutâneo (stent com fármaco)

Objectives: To correlate the permeability and clinical evolution of single and multilateral patients, bearers of obstructive atherosclerosis heart disease in the proximal third of the anterior descending coronary artery (DA), who were submitted to myocardial revascularization using the left internal mammary or underwent a drug eluting stent procedure. Method: This a case history cohort study in which two centers participated. Three hundred patients were retrospectively analyzed, whose lesions were treated at the proximal one third of the DA: in the G-1 group, 150 patients, underwent myocardial revascularization surgery and, the G-2 group, 150 patients, received drug eluting stents, 95 of them received paclitaxel and 55 received sirolimus. All major adverse cardiovascular events were registered during the period (MACE) during the period between the two procedures and the angiographic restudy. Deaths were not included in these MACE, since all patients were restudied through coronariography. There were clinical and angiographic demographic differences between the two groups: the G-1 patients showed a higher incidence of diabetes (29.3% versus 20.0%, p<0.05) and three artery atherosclerosis disease 50% versus 30.6%, p<0.05) with a lower incidence of one artery (13.3% versus 30.6%, p<0.001). Results: The permeability of the two procedures was quite high in both groups. Those patients free of MACE in G-1 RESUMO

Avaliação da acurácia diagnóstica da angiotomografia coronária de múltiplos detectores

INTRODUCTION: Coronary computed tomographic angiography (CCTA) has been widely accepted as a non-invasive diagnostic tool for coronary artery disease (CAD). The objective of this study was to evaluate the diagnostic performance of CCTA and its influence on modification of percutaneous revascularization strategies. METHOD: The study included two groups of patients: a main group (MG), including 100 patients screened with a suspect of severe CAD by CCTA and indication for coronary cineangiography (CINE), and a control group (CG) for comparison, including 100 patients selected during the same period, with indication for CINE according to clinical criteria or by positive functional tests. We evaluated the performance of CCTA for the diagnosis of lesions > 50% in coronary segments, arteries and patients and the revascularization strategies adopted. RESULTS: The sensitivity, specificity and positive and negative predictive values of CCTA were 86%, 95%, 71% and 100% for the coronary segments, 91%, 92%, 80% and 100% for the coronary arteries and 100%, 90%, 100% and 100% for patients, respectively. In the MG, percutaneous coronary intervention (PCI) was performed in 90% of the patients, whereas in the CG, percutaneous coronary intervention was performed in 43% of the patients (P = 0.01). CONCLUSION: CCTA had a high diagnostic performance in detecting CAD and allowed ad hoc PCI to be performed in 90% of the patients. This strategy, however, must await randomized studies to confirm these results.

Intervenção coronária percutânea em pacientes nonagenários

BACKGROUND: Elderly people represent a significant part of the Brazilian population and the population > 90 years has tripled in the past three decades. This retrospective study was aimed at analyzing the results of percutaneous coronary intervention in ninety-year-old patients. METHOD: Overall, 31 ninety-year-old patients (G1) undergoing percutaneous coronary treatment from January 1995 to January 2009 were retrospectively evaluated. These patients were compared to 6,222 patients 2 vessel disease (RR 1.82, IC 1.04-3.19; P = 0.011), left main coronary artery lesion (RR 2.98, IC 0.97-9.17; P = 0.001), presence of unstable angina (RR 2.48, IC 0.97-9.17; P = 0.0013) and diabetes (RR 2.35, IC 1.21-4.55; P = 0.0015) were MACE predicting variables. CONCLUSION: Ninety-year-old patients had a higher incidence of cardiovascular events than younger patients. However, when the technique is feasible and patients have good clinical condition, percutaneous coronary intervention may be effectively used with an acceptable safety margin.

The Relationship of Mitral Valve Prolapse to Obstructive Coronary Artery Disease

The relationship between mitral valve prolapse, segmental and total ventricular function was studied in 121 patients with severe coronary artery disease, 21 of whom had angiographically documented mitral prolapse. The position and movement of the inferior papillary muscle were also analyzed. Mitral valve prolapse in association with severe coronary artery disease does not worsen left ventricular function, nor is it related to ischemic wall motion abnormalities.

Ostial Lesions in Main Coronary Arteries Treated with the Szabo Technique

Background: Percutaneous coronary intervention (PCI) in ostial lesions is one of the major challenges in contemporary interventional cardiology. Despite the technological advances, ostial lesions still present a higher rate of immediate and late adverse events compared with non-ostial lesions. The objective of this study was to evaluate coronary ostial lesions treated with the Szabo technique. Methods: Ten patients treated by PCI using the Szabo technique to treat ostial lesions in main coronary arteries between October and November, 2011, were included. Aorto-ostial lesions were excluded. Results: Of the ten treated patients, seven were males, with ages ranging from 42 to 75 years, and 60% had acute coronary syndromes without ST-segment elevation. The circumflex artery was treated in six patients, and a 7 F catheter was used in eight patients. In three patients, both guidewires twisted during the advancement of the stent to the lesion, which was solved by partially retrieving and repositioning the standard target-vessel wire. Procedural success was observed in 90% of the cases. There were no in-hospital deaths, (re) infarctions or emergency revascularisations. Conclusions: In this study, the Szabo technique successfully treated ostial lesions in main coronary arteries and provided adequate positioning of the stent in most cases.

Desempenho do stent farmacológico firebird em diabéticos portadores de doença coronária multiarterial

BACKGROUND: Preliminary data have shown the Firebird™ and the Cypher® stents have similar safety and efficacy profiles. However, to date, no study has evaluated the percutaneous coronary intervention (PCI) with the Firebird™ stent in diabetic patients. METHODS: The performance of the Firebird™ stent in diabetic patients with multivessel coronary artery disease (CAD) (n = 100) was compared to that of the Cypher® stent, using historical data from the ARTS-II study (n = 159). We compared the major adverse cardiovascular events (MACE) at one year. RESULTS: Most of the patients in the Firebird™ group were male (65%), with mean age of 63.3 ± 10.4 years and 5% were receiving insulin. Stable coronary syndromes were prevalent (60%), 45% had three-vessel CAD and ventricular function was preserved (56.6 ± 13.7%). In patients with three-vessel CAD, 135 lesions were treated with > 3 stents in 78% of the cases and 2 stents in the remaining ones. In patients with two-vessel CAD, 110 lesions were treated with > 2 stents in 80% of the cases and 1 stent in the remaining ones. The incidence of MACE at one year of the Firebird™ stent was 21%, death was observed in 3% of the patients, myocardial infarction in 2% and a new revascularization procedure in 18%, predominantly at the expense of a new PCI in 14% of the cases. Comparison with the Cypher® group did not show differences for any of the evaluated endpoints. CONCLUSIONS: In our study, the use of the Firebird™ stent showed similar results to those of patients in the ARTS-II study, which makes it attractive for use in the complex scenario of diabetic patients with multivessel CAD.

Performance of the Firebird™ Drug-eluting Stent in Diabetic Patients with Multivessel Coronary Artery Disease

Background: Preliminary data have shown that the Firebird TM and the Cypher® stents have similar safety and efficacy profiles. However, to date, no study has evaluated percutaneous coronary intervention (PCI) with the Firebird TM stent in diabetic patients. Methods: The performance of the FirebirdTM stent in diabetic patients with multivessel coronary artery disease (CAD) (n = 100) was compared with that of the Cypher® stent using historical data from the ARTS-II study (n = 159). One-year major adverse cardiovascular events (MACE) were compared. Results: Most of the patients in the FirebirdTM group were male (65%), with a mean age of 63.3 ± 10.4 years, and 5% were on insulin. Stable coronary syndrome was prevalent (60%), and 45% of patients had three-vessel CAD with preserved ventricular function (56.6 ± 13.7%). In patients with three-vessel CAD, 135 lesions were treated with three or more stents in 78% of cases and with two stents in the remainder. In patients with two-vessel CAD, 110 lesions were treated with two or more stents in 80% of the cases and with one stent in the remainder. The one-year incidence of MACE with the FirebirdTM stent was 21%. Mortality occurred in 3% of the patients, myocardial infarction in 2%, and a new revascularisation procedure in 18%, predominantly a new PCI (14% of cases). Comparison with the Cypher® group did not show differences for any of the evaluated endpoints. Conclusions: In the present study, the use of the FirebirdTM stent showed similar results to those of the patients in the ARTS-II study, demonstrating its suitability for use in the complex scenario of diabetic patients with multivessel CAD. DESCRIPTORS: Coronary disease. Angioplasty. Drug-eluting stents. Diabetes mellitus.

Lesões ostiais em artérias coronárias principais tratadas com técnica de Szabo

BACKGROUND:Percutaneous coronary intervention (PCI) in ostial lesions is one of the major challenges for contemporary interventional cardiology. Despite the technological advances, ostial lesions still present a higher rate of immediate and late adverse events when compared to non-ostial lesions. The objective of this study was to evaluate coronary ostial lesions treated with the Szabo technique. METHODS: Series of 10 patients, included between October and November 2011, treated by PCI using the Szabo technique to treat ostial lesions in main coronary arteries. Aorto-ostial lesions were excluded. RESULTS: Of the 10 patients treated, 7 were male, with ages ranging from 42 to 75 years and 60% had acute coronary syndromes without ST-segment elevation. The circumflex artery was treated in 6 patients and a 7 F catheter was used in 8 patients. In 3 patients, during the advancement of the stent to the lesion, both guidewires twisted, which was solved by partially retrieving the standard target vessel wire and positioning it again. Procedural success was observed in 90% of the cases. There were no hospital deaths, (re)infarctions or emergency revascularizations. CONCLUSIONS: In this study, the Szabo technique successfully treated ostial lesions in main coronary arteries, providing adequate positioning of the stent in most of the cases.

Experience with heterotopic heart transplantation in patients with elevated pulmonary vascular resistance: late follow-up

BACKGROUND Along the past few years the number of papers on heterotopic cardiac transplant has been very scarce in the medical literature, including at the international level; this is particularly true in reference to the long term follow-up of these patients and the reason which led to the presentation of our report. OBJECTIVE To report the initial clinical experience and late evolution of 4 patients undergoing heterotopic heart transplantation, indications for this procedure and its major complications. METHODS The surgeries were performed between 1992 and 2001, and all had as indication for heterotopic transplantation the PVR, which ranged from 4.8 WU to 6.5 WU, with a transpulmonary gradient above 15 mmHg. In the 3rd patient, a direct anastomosis between the pulmonary arteries was performed without the use of a prostetic tube, and a mitral valvuloplasty and a LV aneurysmectomy were performed in the native heart. The immediate immunosuppressive regimens were double, with cyclosporine and azathioprine in the first 3 patients, and cyclosporine and mycophenolate mofetil in the 4th patient. RESULTS One immediate death occurred from graft failure, one death occurred after 2 (1/2) years, from endocarditis in an intraventricular thrombus in the native heart, and a third death occurred 6 years after transplantation, from post-operative complications of the aortic valve surgery in the native heart. The remaining patient is well, 15 years after the transplantation. This patient is in functional class II (NYHA), 6 years after a surgical occlusion of the native heart aortic valve. CONCLUSION Heterotopic heart transplantation results are inferior to those of orthotopic heart transplantation because they present higher RVP. The intraventricular thrombi, in the native heart, which require prolonged anticoagulation, and aortic valve complications, also in the native heart, may require surgical treatment. However, a patients 15-year survival has demonstrated a long-term effectiveness of this option for selected patients.BACKGROUND: Along the past few years the number of papers on heterotopic cardiac transplant has been very scarce in the medical literature, including at the international level; this is particularly true in reference to the long term follow-up of these patients and the reason which led to the presentation of our report. OBJECTIVE: To report the initial clinical experience and late evolution of 4 patients undergoing heterotopic heart transplantation, indications for this procedure and its major complications. METHODS: The surgeries were performed between 1992 and 2001, and all had as indication for heterotopic transplantation the PVR, which ranged from 4.8 WU to 6.5WU, with a transpulmonary gradient above 15mmHg. In the 3rd patient, a direct anastomosis between the pulmonary arteries was performed without the use of a prostetic tube, and a mitral valvuloplasty and a LV aneurysmectomy were performed in the native heart. The immediate immunosuppressive regimens were double, with cyclosporine and azathioprine in the first 3 patients, and cyclosporine and mycophenolate mofetil in the 4th patient. RESULTS: One immediate death occurred from graft failure, one death occurred after 2 ½ years, from endocarditis in an intraventricular thrombus in the native heart, and a third death occurred 6 years after transplantation, from post-operative complications of the aortic valve surgery in the native heart. The remaining patient is well, 15 years after the transplantation. This patient is in functional class II (NYHA), 6 years after a surgical occlusion of the native heart aortic valve. CONCLUSION: Heterotopic heart transplantation results are inferior to those of orthotopic heart transplantation because they present higher RVP. The intraventricular thrombi, in the native heart, which require prolonged anticoagulation, and aortic valve complications, also in the native heart, may require surgical treatment. However, a patients 15-year survival has demonstrated a long-term effectiveness of this option for selected patients.

Experiência com transplante cardíaco heterotópico em pacientes com resistência pulmonar elevada: seguimento tardio

BACKGROUND Along the past few years the number of papers on heterotopic cardiac transplant has been very scarce in the medical literature, including at the international level; this is particularly true in reference to the long term follow-up of these patients and the reason which led to the presentation of our report. OBJECTIVE To report the initial clinical experience and late evolution of 4 patients undergoing heterotopic heart transplantation, indications for this procedure and its major complications. METHODS The surgeries were performed between 1992 and 2001, and all had as indication for heterotopic transplantation the PVR, which ranged from 4.8 WU to 6.5 WU, with a transpulmonary gradient above 15 mmHg. In the 3rd patient, a direct anastomosis between the pulmonary arteries was performed without the use of a prostetic tube, and a mitral valvuloplasty and a LV aneurysmectomy were performed in the native heart. The immediate immunosuppressive regimens were double, with cyclosporine and azathioprine in the first 3 patients, and cyclosporine and mycophenolate mofetil in the 4th patient. RESULTS One immediate death occurred from graft failure, one death occurred after 2 (1/2) years, from endocarditis in an intraventricular thrombus in the native heart, and a third death occurred 6 years after transplantation, from post-operative complications of the aortic valve surgery in the native heart. The remaining patient is well, 15 years after the transplantation. This patient is in functional class II (NYHA), 6 years after a surgical occlusion of the native heart aortic valve. CONCLUSION Heterotopic heart transplantation results are inferior to those of orthotopic heart transplantation because they present higher RVP. The intraventricular thrombi, in the native heart, which require prolonged anticoagulation, and aortic valve complications, also in the native heart, may require surgical treatment. However, a patients 15-year survival has demonstrated a long-term effectiveness of this option for selected patients.BACKGROUND: Along the past few years the number of papers on heterotopic cardiac transplant has been very scarce in the medical literature, including at the international level; this is particularly true in reference to the long term follow-up of these patients and the reason which led to the presentation of our report. OBJECTIVE: To report the initial clinical experience and late evolution of 4 patients undergoing heterotopic heart transplantation, indications for this procedure and its major complications. METHODS: The surgeries were performed between 1992 and 2001, and all had as indication for heterotopic transplantation the PVR, which ranged from 4.8 WU to 6.5WU, with a transpulmonary gradient above 15mmHg. In the 3rd patient, a direct anastomosis between the pulmonary arteries was performed without the use of a prostetic tube, and a mitral valvuloplasty and a LV aneurysmectomy were performed in the native heart. The immediate immunosuppressive regimens were double, with cyclosporine and azathioprine in the first 3 patients, and cyclosporine and mycophenolate mofetil in the 4th patient. RESULTS: One immediate death occurred from graft failure, one death occurred after 2 ½ years, from endocarditis in an intraventricular thrombus in the native heart, and a third death occurred 6 years after transplantation, from post-operative complications of the aortic valve surgery in the native heart. The remaining patient is well, 15 years after the transplantation. This patient is in functional class II (NYHA), 6 years after a surgical occlusion of the native heart aortic valve. CONCLUSION: Heterotopic heart transplantation results are inferior to those of orthotopic heart transplantation because they present higher RVP. The intraventricular thrombi, in the native heart, which require prolonged anticoagulation, and aortic valve complications, also in the native heart, may require surgical treatment. However, a patients 15-year survival has demonstrated a long-term effectiveness of this option for selected patients.